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Approach to Improving Safety
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Search results for "Active Errors"

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Web Resource > Multi-use Website

Computer-based Provider Order Entry--CPOE.

ClinfoWiki: The Clinical Informatics Wiki.

This wiki article includes a definition of computer-based provider order entry and other information, such as system elements, implementation tips, and unintended consequences.

Newspaper/Magazine Article

Is your patient ready to go home?

Hoenig LJ. Med Econ. 2006 Jun 2;83:45-46.

The author discusses the importance of thorough discharge examinations.

Journal Article > Study

Operational failures and interruptions in hospital nursing.

Tucker AL, Spear SJ. Health Serv Res. 2006;41:643-662.

This study discovered that nurses experienced more than eight work system failures during an 8-hour shift. Investigators combined primary observation with interview and survey methods to understand the role work system failures play on nurse effectiveness. The most frequent failures identified involved medications, orders, supplies, staffing, and equipment. In addition to operational failures that delayed productivity, a large number of reported work interruptions contributed to the study findings. The authors advocate for continued efforts to differentiate between tactics taken by bedside nurses to prevent error with tactics that result from the system (eg, interruptions), which often put patients at risk for error.

Journal Article > Commentary

The Sorry Works! Coalition: making the case for full disclosure.

Wojcieszak D, Banja J, Houk C. Jt Comm J Qual Patient Saf. 2006;32:344-350.

The authors describe the work of The Sorry Works! Coalition, which aims to minimize the stress and cost associated with medical error by promoting full disclosure and apology.

Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

This monthly selection of medication error reports discusses a mistake with chelation therapy agents due to similar acronym use, confusion of drugs similarly named in different countries, and inadequate information about changes to an existing drug.

Web Resource > Government Resource

National Comparative Audit of Blood Transfusion.

National Blood Service Hospitals.

This Web site includes reports from audits on compliance with blood transfusion guidelines in the United Kingdom.

Special or Theme Issue

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.

Meeting/Conference > Kansas Meeting/Conference

Second Victim Train-the-Trainer Workshop.

Center for Patient Safety and University of Missouri. November 10, 2017; Saint Luke's North Hospital, Barry Road, Kansas City, MO.

Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies to build an organizational program that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.

Meeting/Conference > Massachusetts Meeting/Conference

Improving Patient Safety With Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 26–27, 2017; Constellation Energy Building, Baltimore, MD.

This two-day workshop will discuss of how human factors engineering methods can be applied to identify risks, augment the work environment, and evaluate technology to address potential system failures in health care. 

Meeting/Conference > Massachusetts Meeting/Conference

Patient Safety and Healthcare Quality Improvement 2017.

Harvard Medical School. October 16-17, 2017; Sheraton Boston Hotel, Boston, MA.

This workshop offers insights from safety leaders about applying strategies and guidelines to quality and safety improvement in the acute care setting. This conference has expanded its scope beyond clinicians and patient safety officers to provide educational resources for pharmacists and nurses. Keynote speakers include James Conway and Dr. Thomas H. Lee.

Meeting/Conference > Oregon Meeting/Conference

Speak Up for Patient Safety: Communicating Before, During and After an Adverse Event.

Oregon Patient Safety Commission. August 11, 2017; OMEF Event Center, Portland, OR.

Effective communication among clinical teams and with patients and families is a key component of safe patient care. This workshop will discuss strategies to enhance communication among staff and patients, including concepts from TeamSTEPPS and how to foster a culture that promotes identifying areas for improvement and remaining transparent during an incident.

Meeting/Conference > District of Columbia Meeting/Conference

Improving Diagnosis in Health Care: An Implementation Workshop.

The National Academies of Sciences, Engineering, and Medicine. July 17, 2017; National Academy of Sciences Building, Washington, DC.

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report in 2015. This workshop will discuss progress since the report's release and review strategies for building on those successes to reduce diagnostic error.

Cases & Commentaries

Delayed Recognition of a Positive Blood Culture

  • Web M&M

Sarah Doernberg, MD, MAS; July 2017

A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.

Cases & Commentaries

Pseudo-obstruction But a Real Perforation

  • Spotlight Case
  • CME/CEU
  • Web M&M

Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS; July 2017

Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.

Newspaper/Magazine Article

Death due to pharmacy compounding error reinforces need for safety focus.

ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.

Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.

Newspaper/Magazine Article

Rude providers jeopardize patient safety. So stop it.

Thew J. HealthLeaders Media. June 14, 2017.

Rudeness can affect teamwork and hinder safe, transparent care. This news article reports on one hospital's approach to manage disruptive behavior through strategies such as peer identification and proactive behavior adjustment.

Cases & Commentaries

Chest Tube Complications

  • Web M&M

Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD; June 2017

A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

Cases & Commentaries

Diagnostic Overshadowing Dangers

  • Web M&M

Maria C. Raven, MD, MPH, MSc; June 2017

Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.

Journal Article > Commentary

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

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