Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Camporesi A, Díaz‐Rubio F, Carroll CL, et al. J Paediatr Child Health. 2020;56:1010-1012.
This commentary discusses changes in critical care practice as a response to COVID-19, and the potential for iatrogenic harm to children when diverting from evidence-based medicine during the pandemic crisis.
Sodré Alves BMC, de Andrade TNG, Cerqueira Santos S, et al. J Patient Saf. 2021;17:e1-e9.
This systematic review analyzed five studies discussing adverse events due to medical errors involving high-alert medications. The authors estimated the pooled prevalence at 16.3%, but the included studies reported a wide variation in prevalence (from 3.8% to 100%). The studies also reported a wide range in error severity – up to 19.2% were considered moderate, up to 15.4% were considered serious, and up to 1.9% were considered lethal. The most common medication administration errors involved insulin, potassium chloride, and epoprostenol.
Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. BMJ Qual Saf. 2020;29:550-559.
There is uncertainty about the effectiveness of cognitive debiasing in reducing bias that can contribute to diagnostic error. Instead of focusing on the process of reasoning, this study examined whether an intervention directed at refining knowledge of a cluster of related disease can ‘immunize’ physicians against bias. Ninety-one internal medicine residents in Brazil were randomized to one of two sets of vignettes (reflecting diseases associated with either chronic diarrhea or jaundice) and compared/contrasted alternative diagnoses. After residents encountered one case of a disease, non-immunized residents twice as likely to give that incorrect diagnosis to a different (but similar) disease, resulting in a 40% decrease in diagnostic accuracy between immunized and non-immunized physicians.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.
Lermontov SP, Brasil SC, de Carvalho MR. Cancer Nurs. 2019;42:365-372.
Bone marrow transplantation requires complex drug therapy management. This systematic review identified 11 studies reporting both medication prescription and administration errors, as well as issues such illegible writing, polypharmacy, absence of medication reconciliation, and lack of patient education. These errors resulted in a variety of adverse events. The review identified several prevention measures that can be implemented at the provider-level or systems-level (e.g., computerized prescribing systems).
de Araújo BC, de Melo RC, de Bortoli MC, et al. Front Pharmacol. 2019;10:439.
Prescribing errors are common and can result in patient harm. This review summarizes four key options to reduce prescribing errors: prescriber education, effective use of computerized alert systems at the clinical interface, use of tools and guidance to inform practice, and multidisciplinary teams that include pharmacists.
Tschandl P, Codella N, Akay BN, et al. Lancet Oncol. 2019;20:938-947.
Machine learning may have the potential to improve clinical decision-making and diagnosis. In this study, machine-learning algorithms generally performed better than human experts in accurately diagnosing 7 types of pigmented skin lesions and the top 3 algorithms performed better than the 27 physicians.
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
Silva M das DG, Martins MAP, Viana L de G, et al. Br J Clin Pharmacol. 2018;84:2252-2259.
This study, conducted at a Brazilian hospital, found that the IHI Global Trigger Tool had relatively poor accuracy at identifying adverse drug events among hospitalized patients. The accuracy and reliability of trigger tools have been questioned in other studies.
Bejnordi BE, Veta M, van Diest PJ, et al. JAMA. 2017;318:2199-2210.
Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.
Carlotti APCP, Bachette LG, Carmona F, et al. Am J Clin Pathol. 2016;146:701-708.
This autopsy study demonstrated significant discrepancies between clinical and postmortem diagnoses among children who died in the intensive care unit. These results demonstrate the importance of autopsy as an educational tool for clinical teams to improve patient outcomes.
Freitas PS, Silveira RC de CP, Clark AM, et al. J Clin Nurs. 2016;25:1835-47.
Retained surgical items are considered a never event, but they continue to occur. Summarizing the evidence on surgical counts, this review explores risk factors, current processes, and technology solutions to determine best practices for perioperative nurses to prevent instances of retained surgical items.
Boniatti MM, Azzolini N, Viana M, et al. Crit Care Med. 2014;42:26-30.
Rapid response teams have been widely implemented in hospitals, despite mixed evidence of their benefits. This prospective observational study demonstrated that delayed calls to the rapid response team were associated with higher 30-day mortality.
Plebani M, ed. Clinica Chimica Acta. 2009;404(1):1-86.
This collection of papers presented at an international conference on laboratory medicine focuses on efforts to reduce medical errors in laboratory practice, especially those concerning diagnostic mistakes.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.