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Search results for "Active Errors"

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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.

Journal Article > Study

Overdose risk in young children of women prescribed opioids.

Finkelstein Y, Macdonald EM, Gonzalez A, Sivilotti MLA, Mamdani MM, Juurlink DN; Canadian Drug Safety And Effectiveness Research Network (CDSERN). Pediatrics. 2017;139:e20162887.

Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.

Journal Article > Commentary

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

Newspaper/Magazine Article

Sick children face potentially deadly danger: medication errors.

Furfaro H. Wall Street Journal. September 25, 2016.

Medication errors in pediatric care are common in the hospital and at home. This newspaper article reports on problems associated with medication safety among pediatric patients and highlights several tools both clinicians and parents can use to enhance safety when administering medicine to children, including dosage calculators and pictures depicting medication administration processes.

Journal Article > Commentary

Medication errors in outpatient pediatrics.

Berrier K. MCN Am J Matern Child Nurs. 2016;41:280-286.

Medication errors occur in various care environments, and they are common in the outpatient setting. This commentary describes factors that contribute to incorrect medication administration by parents, such as misunderstanding of instructions due to insufficient health literacy. The author proposes several tactics to promote safe medication practices by parents which include picture-based instructions and standardized dosing instruments.

Journal Article > Study

Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin.

Berthe-Aucejo A, Girard D, Lorrot M, et al. Arch Dis Child. 2016;101:359-364.

This prospective observational study demonstrated that caregivers of pediatric patients experienced difficulties in reconstituting and dosing liquid medications, consistent with prior studies. Family education and enhanced instructions are needed to improve safety of pediatric medication use.

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 > Study

Pediatric emergency department discharge prescriptions requiring pharmacy clarification.

Caruso MC, Gittelman MA, Widecan ML, Luria JW. Pediatr Emerg Care. 2015;31:403-408.

This chart review study found that callbacks from retail pharmacies to a pediatric emergency department were usually related to insurance or clinically insignificant errors, but more than 10% were considered at least significant. These findings demonstrate the need for more robust decision support in electronic prescribing.

Journal Article > Study

The trigger tool as a method to measure harmful medication errors in children.

Maaskant JM, Smeulers M, Bosman D, et al. J Patient Saf. 2015 Apr 7; [Epub ahead of print].

This study compared the performance of a pediatric medication-focused trigger tool with a multifaceted method which relied on chart reviews and voluntary incident reports for detecting harmful medication errors. The multifaceted approach revealed 33 harmful medication errors, whereas the trigger tool failed to pick up any of these incidents and identified only false-positive events in this sample.

Journal Article > Review

Interventions for reducing medication errors in children in hospital.

Maaskant JM, Vermeulen H, Apampa B, et al. Cochrane Database Syst Rev. 2015;3:CD006208.

Exploring the literature on efforts to reduce medication errors in hospitalized children, this systematic review examined five interventions, including introduction of computerized provider order entry systems, clinical pharmacist participation in the frontline care team, and implementation of barcode medication administration systems. Although the interventions showed some success, none of the studies found a significant reduction in patient harm.

Journal Article > Study

Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.

Bank I, Snell L, Bhanji F. Pediatr Emerg Care. 2014;30:879-883.

Emergency medicine residents receive variable exposure to pediatric resuscitation situations during their training, highlighting the need for effective simulation–based education. In this study, a crew resource management–based teamwork training workshop increased emergency medicine residents' knowledge of teamwork concepts and enhanced their ability to detect errors.

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 > Study

A step toward high reliability: implementation of a daily safety brief in a children's hospital.

Saysana M, McCaskey M, Cox E, Thompson R, Tuttle LK, Haut PR. J Patient Saf. 2014 Aug 12; [Epub ahead of print].

This study describes the implementation of a daily safety brief at a children's hospital. The daily brief uncovered many unexpected outcomes and generally took less than 15 minutes each day. Participants felt this meeting improved awareness of daily events and communication between departments.

Journal Article > Study

Decreasing handoff-related care failures in children's hospitals.

Bigham MT, Logsdon TR, Manicone PE, et al. Pediatrics. 2014;134:e572-e579.

Discontinuity between providers is a well-known source of errors, with problems arising from handoffs and signouts both in hospital and at hospital discharge. This quality improvement initiative aimed to enhance handoffs in 23 children's hospitals over a 12-month period. Following introduction of a structured handoff tool, handoff-related care failures declined and provider satisfaction with handoffs increased. Handoff-related care failures were defined as insufficient information transfer that affected the patient, such as reporting inaccurate test results or miscommunication that led to duplicated medications. This study is the largest to date of a standardized handoff approach, and these results are consistent with prior smaller studies. A past AHRQ WebM&M commentary describes pitfalls of handoffs.

Journal Article > Commentary

Nearing zero...reducing grade C medication errors.

Cockerham J, Figueroa-Altmann A, Foxen C, Paffett C, Sullivan A, Wellner J. Nurs Manage. 2014;45:26-31.

This commentary outlines an initiative at a 15-bed pediatric nursing unit that used quiet zones, safety huddles, and independent double checks to reduce medication errors of the type that reach the patient but neither cause harm nor require additional intervention.

Journal Article > Study

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.

Hardmeier A, Tsourounis C, Moore M, Abbott WE, Guglielmo BJ. J Healthc Qual. 2014;36:54-63.

After implementation of a barcode medication administration system at a children's hospital, adherence to institutional medication safety protocols was high and the incidence of medication administration errors appeared to be low based on direct observation.

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.

Newspaper/Magazine Article

Children's Hospital investigated five patient deaths from deadly fungal disease in 2009.

Catalanello R. The Times-Picayune. April 15, 2014.

Reporting on the investigation into an incident where five pediatric patients died after acquiring a health care–associated infection, this newspaper article describes how delays in diagnosis and treatment along with inadequate communication contributed to patient harm.

Journal Article > Review

Quality and safety in pediatric hematology/oncology.

Mueller BU. Pediatr Blood Cancer. 2014;61:966-969.

Children with cancer are particularly vulnerable to medication errors. This review describes how to enhance safe medication use in pediatric oncology through establishing a safety culture, integrating high reliability principles, and teamwork training.

Journal Article > Study

Paediatric nurses' adherence to the double-checking process during medication administration in a children's hospital: an observational study.

Alsulami Z, Choonara I, Conroy S. J Adv Nurs. 2014;70:1404-1413.

On many hospital wards, standard policy calls for two nurses to double-check medications prior to administration, despite a lack of consistent evidence supporting this strategy. In this prospective observational study, pediatric nurses independently double-checked only 30% of drug administrations and adherence varied between weekdays and weekends.

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