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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.

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.

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.

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.

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.

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 > 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.

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 > Review

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis.

Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. Neurology. 2017;88:1468-1477.

Delayed diagnosis of stroke can lead to preventable disability. This meta-analysis of diagnostic accuracy for cerebrovascular events in the emergency department found that overall 9% of strokes were misdiagnosed. The risk of misdiagnosis was higher if stroke symptoms were transient, nonspecific, or mild. The authors suggest that interventions to improve stroke diagnosis should focus on these specific disease presentations.

Journal Article > Commentary

Elimination of emergency department medication errors due to estimated weights.

Greenwalt M, Griffen D, Wilkerson J. BMJ Qual Improv Rep. 2017;6:u214416.w5476.

Inaccurate assessments of patient weight can lead to medication dosing errors. This commentary describes how a single-center quality improvement project drew from errors in the emergency department associated with incorrect patient weight estimates and applied storytelling, Lean Six Sigma, and Fishbone diagram approaches to develop and test a method of entering weights that eliminated these errors during the 6-month intervention period.

Journal Article > Study

We are going to name names and call you out! Improving the team in the academic operating room environment.

Bodor R, Nguyen BJ, Broder K. Ann Plast Surg. 2017;78(suppl 4):S222-S224.

This study of operating room teams found that nursing staff, attending surgeons, and anesthesiologists did not always know the name or postgraduate year rank of trainees participating in surgery with them. The authors describe this lack of familiarity with team members as a knowledge gap that has the potential to affect surgical safety.

Journal Article > Commentary

Learning and mindfulness: improving perioperative patient safety.

Graling PR, Sanchez JA. AORN J. 2017;105:317-321.

The surgical environment is complex, and strategies to address human error and learn from mistakes are important to improve safety in this setting. This commentary discusses how organizational learning and mindfulness can help perioperative staff manage and prevent missteps in the operating room.

Journal Article > Study

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

Wong A, Amato MG, Seger DL, et al. J Crit Care. 2017;39:156-161.

This retrospective study reviewed more than 47,000 overridden medication alerts and found that the vast majority of overrides were clinically appropriate and did not cause harm. From this sample, 7 adverse drug events were identified, and these events were more likely when the alerts were overridden in error. This study demonstrates the challenge of identifying clinically important alerts in a setting where alert fatigue is common.

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