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Search results for "Active Errors"

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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

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.

Journal Article > Review

Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents.

  • Classic

Ferrah N, Lovell JJ, Ibrahim JE. J Am Geriatr Soc. 2017;65:433-442.

Older adults living in long-term care facilities face significant safety hazards. This systematic review examined medication errors in nursing homes and found a high prevalence of errors overall. The review revealed that a significant number of errors were related to handoffs and that 75% of these older patients received at least one potentially inappropriate medication. However, serious harm associated with medication use was reported for less than 1% of errors. The authors emphasize the difficulty of attributing harm to medications versus underlying illness in nursing home residents, and they call for designing safer systems for medication administration in nursing homes. A previous WebM&M commentary discussed challenges to ensuring patient safety in long-term care facilities.

Journal Article > Study

Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study.

van Welie S, Wijma L, Beerden T, van Doormaal J, Taxis K. BMJ Open. 2016;6:e012286.

Not all pill-form medications can be safely crushed to administer to patients who have difficulty swallowing. In this before and after intervention study in a nursing home, adding warning symbols and educating staff about crushing medications led to a decrease in pill-crushing errors. The authors conclude that education and warnings enhanced this aspect of medication safety.

Journal Article > Commentary

Preventing medication errors.

Stefanacci RG, Riddle A. Geriatr Nurs. 2016;37:307-310.

Nursing home patients are particularly vulnerable to medication errors. This commentary describes an incident involving a medication error and reviews conditions in long-term care that increase the potential for similar errors to occur. The authors suggest that proactive system improvements must address weaknesses in ordering, administration, compliance, and medication reconciliation.

Tools/Toolkit > Fact Sheet/FAQs

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

Horsham, PA: Institute of Safe Medication Practices; 2016.

Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.

Journal Article > Commentary

Reporting medication errors: residents with diabetes.

Milligan F, Gadsby R, Ghaleb M, et al. Nurs Resid Care. 2014;16:617-621.

Patients in nursing homes are particularly vulnerable to medication errors. Exploring the unique factors that affect medication safety in nursing home residents with diabetes, this review emphasizes the contrasting need to establish a safety culture while promoting incident reporting of errors, which has been inconsistent in this setting due to fear of blame.

Audiovisual > Audiovisual Presentation

Applying High Reliability Principles to Infection Prevention and Control in Long Term Care.

Oakbrook Terrace, IL: Joint Commission; 2014.

Safety problems, particularly medication errors and poor hand hygiene compliance, are common in nursing homes. This Web site offers an online learning module and related information about how to apply high reliability concepts to reduce health care–associated infections in long-term care settings.

Journal Article > Study

Antibiotic prescribing practice in residential aged care facilities—health care providers' perspectives.

Lim CJ, Kwong MWL, Stuart RL, et al. Med J Aust. 2014;201:101-105.

This qualitative study explored barriers to appropriate antibiotic use in residential aged care facilities in Australia. Several organizational and cultural issues emerged, including inadequate staffing of on-site physicians which placed the burden of infection diagnosis and management on nurses not sufficiently trained to perform this role.

Journal Article > Study

Outcomes of a quality improvement project for educating nurses on medication administration and errors in nursing homes.

Tenhunen ML, Tanner EK, Dahlen R. J Contin Educ Nurs. 2014;45:306-311.

This quality improvement study found that an educational video designed to improve medication safety in nursing homes successfully enhanced nurses' knowledge about medication administration practices. A recent AHRQ WebM&M commentary discusses medication safety in nursing homes.

Cases & Commentaries

SNFs: Opening the Black Box

  • Web M&M

Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP; December 2013

Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.

ISMP Long-Term Care Advise-ERR.

Institute for Safe Medication Practices. 200 Lakeside Drive, Suite 200; Horsham, PA 19044.

This newsletter focuses on medication safety concerns that administrators, nurses, and other health care workers may encounter while providing long-term care services.

Journal Article > Study

Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.

Desai RJ, Williams CE, Greene SB, Pierson S, Hansen RA. J Healthc Risk Manag. 2013;33:33-43.

Patients in nursing homes are generally elderly, chronically ill, and take multiple medications, which places them at higher risk for medication errors. The state of North Carolina maintains a mandatory medication error reporting system for all nursing homes. This study analyzed data from this system to characterize errors due to anticoagulant drugs (which are considered high-risk medications). Errors were found to be common and harmful, often due to inadequate monitoring to ensure appropriate drug dosing. The authors recommend several potential solutions, but any interventions will likely also have to address the fact that safety culture in nursing homes is generally poor. An AHRQ WebM&M commentary discusses a preventable error due to inadequate monitoring of the anticoagulant warfarin at a nursing home, and an AHRQ WebM&M perspective explores the difficult problem of ensuring medication safety in nursing facilities.

Newspaper/Magazine Article

Difficulty identifying Alzheimer's makes misdiagnosis easy.

Ackerman T. Houston Chronicle. November 23, 2012.

This newspaper article describes challenges that may precipitate underdiagnosis or misdiagnosis of Alzheimer disease and conditions with similar presenting symptoms.

Cases & Commentaries

Buprenorphine and the Medically Ill Patient

  • Web M&M

Elinore F. McCance-Katz, MD, PhD; October 2012

A man with a long history of opioid dependence (and smoking) went to a substance abuse program for detoxification. The patient received buprenorphine/naloxone and was found unresponsive and cyanotic a few hours later. He was diagnosed with opiate-induced respiratory distress complicated by pneumonia and chronic obstructive pulmonary disease.

Journal Article > Study

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.

Medication errors are common in long-term care facilities, and prior research has shown that many of these errors occur at medication administration. This is particularly a problem at assisted living facilities where non-nursing clinical staff (such as medication aides) are often charged with administering medications. Direct observation of medication administration at two assisted living facilities in this study found that the overall error rate was similar between nurses and non-nurses, but less trained staff from either discipline had markedly higher error rates. As the regulations regarding medication administration in assisted living facilities vary from state to state, the authors advocate for more uniform training standards for all staff authorized to administer medications.

Book/Report

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2017.

This report summarizes progress in patient safety improvement in the past decade and reviews the 2016 activities of the Patient Safety Authority, including an initiative to improve the standardization of their reporting process that resulted in an increase of serious events reported and an effort that reduced health care–associated infections in nursing homes.

Journal Article > Study

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

Crespin DJ, Modi AV, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-270.

This study found that 37% of medication errors were repeated one or more times in nursing home settings, with wrong dosage and wrong administration as the most frequent causes. While the absolute harm rates were small, repeat errors were twice as likely to be harmful to patients compared to non-repeated ones.

Journal Article > Study

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

North Carolina law requires all nursing homes to report medication errors, as discussed in a prior article. Analysis of medication error reports submitted to this Web-based error reporting system revealed that most of the serious errors occurred during evening shifts and involved drugs given to the wrong patient.

Journal Article > Study

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.

This study found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.

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