Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
1 - 20 of 63

Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.
Procaccini D, Rapaport R, Petty BG, et al. Jt Comm J Qual Patient Saf. 2020;46(12):706-714.
The use of PRN (“as needed”) medications is a common source of medication errors. The authors describe the implementation of staff education and a pediatric intensive care unit (PICU) order set (with predefined PRN orders), which led to increased compliance with Joint Commission medication management standards. The related editorial discusses how investment in human factors and ergonomics can contribute to healthcare quality and safety improvements.

A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died.

Smalley CM, Willner MA, Muir MKR, et al. Am J Emerg Med. 2020;38(8):1647-1651.
This study assessed the impact of electronic health record (EHR) interventions to standardize opioid prescribing practices across a large health system. Interventions included (1) deleting clinician preference lists, (2) default dose, frequency, and quantity, (3) standardizing formularies, and (4) dashboards with current opioid prescribing practices. In the 12 months after implementation, there was a decrease in the rate of opioid prescriptions overall, prescriptions exceeding three days, prescriptions exceeding prespecified morphine equivalent doses, and non-formulary prescriptions.
Kuitunen SK, Niittynen I, Airaksinen M, et al. J Patient Saf. 2020:Epub Mar 14.
The objective of this systematic review was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies; the authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.
Fearon NJ, Benfante N, Assel M, et al. Jt Comm J Qual Patient Saf. 2020;46(7):410-416.
Opioid prescriptions are associated with harm among postoperative patients. This quality improvement project reduced and standardize opioid prescriptions upon discharge for opioid-naive patients undergoing oncologic surgery and evaluated the impact on subsequent opioid use and reported pain. Pre-standardization, the median opioid prescription at discharge was 20 pills (up to 140 milligrams morphine equivalent, or MME); post-standardization, prescriptions were set to 7-10 pills (24-75 MME) depending on the type of oncologic surgery.
Hess E, Palmer SE, Stivers A, et al. J Oncol Pharm Pract. 2020;26(4):787-793.
This study used one cancer hospital’s incident reporting system to evaluate trends in medication error reporting before and after the implementation of a new electronic health record (EHR) system. After implementation, decreases in reporting were observed for wrong-dose, overdose, wrong duration, and wrong frequency medication errors, likely due to EHR tools such as hard stops on medication doses or prohibiting early or late administration.

ISMP Medication Safety Alert! Acute Care Edition. May 22, 2020;25(10).

Smart infusion pumps are widely used in hospitals to reduce medication errors but have the potential to create problems if not correctly used. This article discusses heparin administration programming errors and recommends independent double-checks, electronic health record and smart pump interoperability and weight-based dosing as tactics to minimize mistakes.   
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Lifflander AL. JAMA. 2019;321:837-838.
Implementing new information systems can have unintended consequences on processes. This commentary explores insights from a physician, both as a clinician and as the family member of a patient, regarding the impact of hard stops in electronic health records intended to prevent gaps in data entry prior to task progression. The author raises awareness of the potential for patient harm due to interruptions and diminishing student and clinician skill in asking questions to build effective patient histories.
O'Sullivan ED, Schofield SJ. BMC medical education. 2019;19(1):12.
This simulation study randomized physicians to identify the correct diagnosis in a standardized case, either with the aid of a debiasing exercise or without any prompting. Even though the participants believed that the debiasing tool was effective, it did not improve diagnostic accuracy. These results underscore the challenge of enhancing diagnostic cognition.
Powers EM, Shiffman RN, Melnick ER, et al. J Am Med Inform Assoc. 2018;25:1556-1566.
Although hard-stop alerts can improve safety, they have been shown to result in unintended consequences such as delays in care. This systematic review suggests that while implementing hard stops can lead to improved health and process outcomes, end-user involvement is essential to inform design and appropriate workflow integration.
Gibbs HG, McLernon T, Call R, et al. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2017;74:2054-2059.
This quality improvement intervention sought to decrease wrong-patient errors with insulin pens by storing them in locked boxes in patient rooms. Four hospital units had a formal policy change for insulin pen storage, and four units provided education to nurses about insulin pen storage. Researchers found that the policy change was more effective than education in spurring adherence to in-room insulin pen storage guidelines.
Hospitalized for pneumonia, a woman with a history of alcohol abuse and depression was found unconscious on the medical ward. A toxicology panel revealed her blood alcohol level was elevated at 530 mg/dL. A search of the ward revealed several empty containers of alcoholic foam sanitizer, which the patient confessed to ingesting.
Westbrook JI, Li L, Hooper TD, et al. BMJ quality & safety. 2017;26:734-742.
This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.
Harada S, Suzuki A, Nishida S, et al. Journal of evaluation in clinical practice. 2017;23:582-585.
Insulin is known to be a high-risk medication. This pre–post study found that introduction of a standardized sliding scale insulin order led to decreased rates of insulin prescribing errors. However, the incidence of hyperglycemia or hypoglycemia did not change. This study demonstrates how standardization can support patient safety.
Bates KE, Shea JA, Bird GL, et al. Joint Commission journal on quality and patient safety. 2016;42:562-AP4.
Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.
Lohmann K, Gartner D, Kurze R, et al. J Clin Pharm Ther. 2015;40(2):220-225.
Crushing pills or capsules is sometimes necessary when a patient is not capable of swallowing normally, but this can also be a source of medication errors. This study, conducted in a university hospital in Germany, demonstrated a significant reduction in inappropriate crushing of medications after an intensive educational program.
Green RA, Hripcsak G, Salmasian H, et al. Annals of emergency medicine. 2015;65:679-686.e1.
While computerized physician order entry is expected to significantly reduce adverse drug events, systems must be implemented thoughtfully to avoid facilitating certain types of errors. A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient prescribing errors within a computerized provider order entry system.