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Search results for "Active Errors"

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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.

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 > 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

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.

Cases & Commentaries

One Dose, Two Errors

  • Web M&M

Gregory A. Filice, MD; December 2016

An older woman experienced acute kidney injury after being prescribed a nephrotoxic medication (amphotericin) intended for the ICU patient in the next bed. Caring for both patients, the covering resident entered the medication order for the wrong patient despite a policy requiring infectious disease consultation to prescribe IV amphotericin.

Journal Article > Study

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

Jones A, Johnstone MJ. Aust Crit Care. 2017;30:219-223.

This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.

Journal Article > Study

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

van Galen LS, Struik PW, Driesen BEJM, et al. PLoS One. 2016;11:e0161393.

Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.

Cases & Commentaries

Cognitive Overload in the ICU

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

Vimla L. Patel, PhD, and Timothy G. Buchman, PhD, MD; July/August 2016

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

Journal Article > Study

An observational study of adult admissions to a medical ICU due to adverse drug events.

Jolivot PA, Pichereau C, Hindlet P, et al. Ann Intensive Care. 2016;6:9.

Examining adverse drug events that led to admission to the intensive care unit, this study found that more than half of events were preventable. Non-compliance to medication, which leads to worsening of underlying conditions, was the most common cause of preventable adverse drug events.

Journal Article > Study

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

Hughes KM, Goswami ES, Morris JL. J Pediatr Pharmacol Ther. 2015;20:453-461.

Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.

Journal Article > Review

Interruptions and medication administration in critical care.

Bower R, Jackson C, Manning JC. Nurs Crit Care. 2015;20:183-195.

Interruptions occur frequently during the medication process, and previous studies examined whether they increase risks. This review explores the literature on the impact of interruptions during medication administration to determine factors that contribute to interruptions and how to address them.

Journal Article > Review

Diagnostic errors in the pediatric and neonatal ICU: a systematic review.

Custer JW, Winters BD, Goode V, et al. Pediatr Crit Care Med. 2015;16:29-36.

Previous autopsy studies have found an error rate of nearly 9%, implying that thousands of patients die every year due to diagnostic errors. This systemic review of diagnostic errors in pediatric and neonatal intensive care unit (ICU) settings synthesized results of 13 studies of autopsies that confirmed diagnostic errors. The most common type of missed diagnosis found at autopsy was infection. Other prevalent missed diagnoses included vascular events and congenital conditions. The authors estimate that 6.4% of pediatric ICU deaths and 3.7% of neonatal ICU deaths are attributable to major missed diagnosis. This work argues for more prospective investigation of missed and delayed diagnoses as well as more routine autopsies in pediatric and neonatal ICU settings. A past AHRQ WebM&M commentary discussed the value of autopsies in understanding misdiagnoses.

Journal Article > Study

Error in intensive care: psychological repercussions and defense mechanisms among health professionals.

Laurent A, Aubert L, Chahraoui K, et al. Crit Care Med. 2014;42:2370-2378.

This interview study found that physicians and nurses experience guilt and shame following errors, echoing previous studies of the health care provider as the second victim in adverse events. A past AHRQ WebM&M interview with Dr. Albert Wu discusses the impact of errors on health care providers.

Journal Article > Study

Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.

Donaldson N, Aydin C, Fridman M, Foley M. J Healthc Qual. 2014;36:58-68.

This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.

Journal Article > Study

The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit.

Panesar RS, Albert B, Messina C, Parker M. Am J Med Qual. 2016;31:64-68.

Use of a structured communication tool within an electronic medical record resulted in increased high-quality communication between nurses and physicians around critical patient events.

Journal Article > Review

Reducing medication errors in critical care: a multimodal approach.

Kruer RM, Jarrell AS, Latif A. Clin Pharmacol. 2014;6:117-126.

In light of Institute of Medicine recommendations to redesign drug packaging and labeling to decrease medication errors, this review highlights challenges to medication safety in the intensive care unit associated with drug formulations and various routes of administration. The authors recommend a multimodal approach that combines system-level interventions, such as computerized provider order entry, simulation training, barcode medication administration, and incident reporting, to prevent adverse drug events.

Cases & Commentaries

Too Much, Too Fast

  • Web M&M

Delphine Tuot, MDCM, MAS; September 2014

A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful.

Journal Article > Study

Parents' perspective on safety in neonatal intensive care: a mixed-methods study.

Lyndon A, Jacobson CH, Fagan KM, Wisner K, Franck LS. BMJ Qual Saf. 2014; 23:902-909.

This interview, observation, and survey study found that parents of infants in neonatal intensive care units identified three core aspects of safety: physical safety relating to immediate treatment, the effect of care on future development, and emotional safety for infants and family, such as having confidence in caregivers. These results argue for enhancing patient and family engagement in safety in this setting.

Journal Article > Study

Use of a daily goals checklist for morning ICU rounds: a mixed-methods study.

Centofanti JE, Duan EH, Hoad NC, et al. Crit Care Med. 2014;42:1797-1803.

This direct observation study found frequent use of and satisfaction with a checklist of daily goals for patients in an intensive care unit. The intervention was associated with improved communication and fewer errors of omission. Although checklists are widely promoted for patient safety, a recent study suggests that they should be evaluated after implementation.

Journal Article > Study

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.

Sacks GD, Diggs BS, Hadjizacharia P, Green D, Salim A, Malinoski DJ. Am J Surg. 2014;207:817-823.

The introduction of the Institute for Healthcare Improvement central line bundle into a surgical intensive care unit dramatically reduced the incidence of central line–associated bloodstream infections, preventing an estimated 2.5 deaths per year in this single unit.

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