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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.

Patient Safety Primers

Falls

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

Journal Article > Commentary

Implementation of a modified bedside handoff for a postpartum unit.

Wollenhaup CA, Stevenson EL, Thompson J, Gordon HA, Nunn G. J Nurs Adm. 2017;47:320-326.

Ineffective team communication can contribute to sentinel events. This commentary describes how a rural hospital's postpartum unit redesigned its handoff process to create a bedside handoff model and utilized structured educational modalities and nurse champions to drive improvement and acceptance of the approach.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Study

Proactive risk assessment of surgical site infections in ambulatory surgery centers.

Bish EK, Azadeh-Fard N, Steighner LA, Hall KK, Slonim AD. J Patient Saf. 2017;13:69-75.

This study reports on the use of a prospective risk assessment tool to identify risks for surgical site infection in an ambulatory surgery center. A safety intervention was developed that specifically targeted the vulnerabilities identified by the risk assessment. Other methods of prospective error detection are discussed in the Detection of Safety Hazards Patient Safety Primer.

Cases & Commentaries

The Perils of Contrast Media

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

Umar Sadat, MD, PhD, and Richard Solomon, MD; June 2017

To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

Journal Article > Study

Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.

Sparks JL, Crouch DL, Sobba K, et al. JAMA Surg. 2017 May 24; [Epub ahead of print].

Multiple studies have linked poor teamwork and communication to adverse events in the operating room. There is a growing recognition that surgeons must learn these nontechnical skills during training in addition to the traditional focus on technical ability. In this controlled study, surgical residents participated in an educational intervention (a simulated surgical emergency) that simultaneously targeted technical and nontechnical skill development. The study used two different types of simulation—high fidelity (a cadaver) and medium fidelity (an anatomically correct mannequin)—compared to a control group, which used a nonanatomic simulator. Investigators found that nontechnical skills improved in both intervention groups compared to the control group, measured using validated teamwork assessments. As the accompanying editorial notes, the study findings indicate that technical and nontechnical skills may be best taught together, as teamwork skills improved when residents also had to perform a simulated surgical task simultaneously.

Journal Article > Commentary

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review.

Henriksen K, Dymek C, Harrison MI, Brady JP, Arnold SB. Diagnosis. 2017 May 23; [Epub ahead of print].

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report. This commentary reviews insights shared at a conference convened to discuss issues associated with diagnosis, including the need for concrete definitions of diagnostic error, the role of technology in improvement, and organizational factors that contribute to the problem.

Journal Article > Study

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

Mody L, Greene MT, Meddings J, et al. JAMA Intern Med. 2017 May 19; [Epub ahead of print].

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

Newspaper/Magazine Article

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.

Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.

Newspaper/Magazine Article

The last person you'd expect to die in childbirth.

Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.

Maternal mortality is increasing in the United States. This news article reports on this critical safety problem in the context of the preventable death of a patient whose diagnosis of preeclampsia was missed by her providers, despite persistent concerns raised by family about the patient's symptoms.

Journal Article > Commentary

Farewell to a cancer that never was.

Lyon J. JAMA. 2017;317:1824-1825.

Overdiagnosis can result in financial, psychological, and physical harm for patients. This commentary discusses the reclassification of a subtype of thyroid cancer as a nonmalignancy and the impact changing guidelines can have on patients.

Journal Article > Study

Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit.

Solanki R, Mondal N, Mahalakshmy T, Bhat V. Arch Dis Child. 2017 May 3; [Epub ahead of print].

Pediatric patients are at high risk for medication errors. Researchers conducted a cross-sectional study on 166 infants younger than 3 months who were discharged from the hospital. They found a high frequency of medication errors by caregivers. In keeping with prior research, dose administration errors were the most common type of error.

Journal Article > Commentary

An innovative collaborative model of care for undiagnosed complex medical conditions.

Nageswaran S, Donoghue N, Mitchell A, Givner LB. Pediatrics. 2017;139:e20163373.

Lack of collaboration among the clinical team can contribute to diagnostic problems. This commentary describes a collaborative model of care developed to enhance interdisciplinary teamwork across health care settings as a strategy to augment diagnosis for children with undiagnosed complex medical conditions.

Cases & Commentaries

Communication Error in a Closed ICU

  • Web M&M

Barbara Haas, MD, PhD, and Lesley Gotlib Conn, PhD; May 2017

Admitted to the ICU with septic shock, a man with a transplanted kidney developed hypotension and required new central venous access. Since providers anticipated using the patient's left internal jugular vein catheter for re-starting hemodialysis (making it unsuitable to use for resuscitation), the ICU team placed the central line in the right femoral vein. However, they failed to recognize that his transplanted kidney was on the right side, which meant that femoral catheter placement on that side was contraindicated.

Cases & Commentaries

Diagnostic Delay in the Emergency Department

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

Kyle Marshall, MD, and Hardeep Singh, MD, MPH; May 2017

Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.

Journal Article > Study

Evaluating serial strategies for preventing wrong-patient orders in the NICU.

Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139:e20162863.

Wrong-patient errors are a well-established risk in the health care setting. Research has shown that providers, often multitasking, may enter notes or medication orders for the wrong patient. A prior study touted point-of-care photographs as a helpful intervention for identifying and preventing wrong-patient errors in a cardiothoracic intensive care unit. However, less is known about wrong-patient errors in the neonatal intensive care unit (NICU) population and ways to prevent them. Researchers analyzed more than 850,000 NICU orders and more than 3.5 million non-NICU orders in pediatric patients over a 7-year period. At baseline, they found that wrong-patient orders occurred more frequently in the NICU population with an odds ratio of 1.56. Interventions included requiring reentry of patient identifiers prior to order entry as well as a new naming system for newborns. Implementation of both led to a 61.1% reduction in wrong-patient errors in the NICU population from baseline. A previous WebM&M commentary highlights a case of wrong-patient identification.

Journal Article > Study

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Cases & Commentaries

Hemolysis Holdup

  • Web M&M

Christopher M. Lehman, MD; May 2017

In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.

Journal Article > Study

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

Harris LM, Dreyer BP, Mendelsohn AL, et al. Acad Pediatr. 2017;17:403-410.

Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.

Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Journal Article > Review

Improving patient safety in handover from intensive care unit to general ward: a systematic review.

Wibrandt I, Lippert A. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

This systematic review of handoffs from intensive care to general ward identified eight intervention studies, none of which demonstrated improved mortality or lower readmission rates. Handoff strategies differed widely among the included studies. The authors recommend further study to identify best handoff practices for patients discharged from intensive care.

Journal Article > Study

Quality of handoffs in community pharmacies.

Abebe E, Stone JA, Lester CA, Chui MA. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.

Journal Article > Study

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

Martinez W, Lehmann LS, Thomas EJ, et al. BMJ Qual Saf. 2017 Apr 25; [Epub ahead of print].

Health care provider comfort with raising patient safety concerns is a critical aspect of safety culture. This survey of resident physicians at six academic medical centers demonstrated that trainees remain reluctant to speak up. Nearly half reported observing a patient safety threat. The majority spoke up about patient safety concerns, but a significant proportion did not. Although unprofessional behavior was more frequently observed, fewer trainees raised concerns about lack of professionalism than about patient safety. Even when respondents perceived the unprofessional behavior as having high potential for adverse patient consequences, they were not as likely to speak up about this compared to a traditional patient safety threat such as inadequate hand hygiene. The authors recommend specifically measuring tolerance for unprofessional behaviors as a part of safety culture assessment.

Journal Article > Commentary

Polypharmacy in the elderly—when good drugs lead to bad outcomes: a teachable moment.

Carroll C, Hassanin A. JAMA Intern Med. 2017 Apr 24; [Epub ahead of print].

Geriatric patients are particularly vulnerable to adverse drug events due to comorbidities, complicated care plans, and polypharmacy. This commentary describes how using STOPP criteria and performing indication mapping can help reduce polypharmacy and improve patient safety.

Journal Article > Study

Prescription errors related to the use of computerized provider order-entry system for pediatric patients.

Alhanout K, Bun SS, Retornaz K, Chiche L, Colombini N. Int J Med Inform. 2017;103:15-19.

Computerized provider order entry has been shown to decrease adverse drug events, but it can also introduce new medication errors. This retrospective study examined medication ordering errors intercepted by pharmacists for pediatric patients. As with prior studies in pediatrics, this investigation uncovered dosing errors associated with weight-based dosing, including calculation errors and missing weight information. The most common medication associated with errors was acetaminophen, which can cause severe harm if incorrectly dosed. The authors call for improving electronic health record prescribing interfaces, better user training, and enhancing communication among providers to prevent medication errors.

Journal Article > Study

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.

Sharma M, Krishnamurthy M, Snyder R, Mauro J. Clin Pract. 2017;7:953.

Anticoagulants are considered high-risk medications due to their narrow therapeutic window and association with adverse drug events. This study suggests that integration of a clinical pharmacist into the inpatient team may help prevent anticoagulation dosing errors and resultant harm to patients.

Journal Article > Study

Extent of diagnostic agreement among medical referrals.

Van Such M, Lohr R, Beckman T, Naessens JM. J Eval Clin Pract. 2017 Apr 4; [Epub ahead of print].

Diagnostic uncertainty is common and can lead to missed or delayed diagnoses. This retrospective medical record review study examined cases where primary care providers sought diagnostic input from subspecialists. Investigators compared the final diagnosis from the subspecialty visit with the presumed diagnosis at the time of the initial subspecialty referral. They found that the diagnosis differed substantially in about one-fifth of cases following the subspecialty consultation. Costs were higher for cases with substantively different diagnoses compared to cases where subspecialists confirmed or further clarified diagnoses. The authors conclude that subspecialty access is critical to timely and accurate diagnosis. A recent WebM&M commentary discussed how cognition can influence diagnostic decision making.

Journal Article > Study

Innovative use of the electronic health record to support harm reduction efforts.

Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Pediatrics. 2017;139:e20153410.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.

Cases & Commentaries

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

  • Web M&M

Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

Journal Article > Study

Pathologists' perspectives on disclosing harmful pathology error.

Dintzis SM, Clennon EK, Prouty CD, Reich LM, Elmore JG, Gallagher TH. Arch Pathol Lab Med. 2017;141:841-845.

Disclosure of medical errors is a recommended patient safety practice. This focus group study of pathologists found that most pathologists believe treating clinicians should disclose pathology errors and express concern that treating clinicians do not understand the inherent limitations of pathologic diagnosis. The authors suggest that developing consensus guidelines may improve disclosure of pathology errors.

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