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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

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.

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.

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 > 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 > 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 > 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

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study.

Gilmartin-Thomas JF, Smith F, Wolfe R, Jani Y. Int J Nurs Stud. 2017;72:15-23.

This prospective, direct-observation study examined medication administration accuracy of medications dispensed by nurses and caregivers in long-term care facilities. Investigators compared medication administration from original medication packaging to administration from multicompartment medication devices. The team observed nearly 2500 doses. When medications were dispensed from original packaging, the medication administration error rate was 9%. When multicompartment devices were used, the medication administration error rate was 3%. This difference persisted in settings where both original packaging and multicompartment medication devices were used. This study adds to the evidence about how literacy-friendly health systems can enhance medication safety.

Journal Article > Study

All consumer medication information is not created equal: implications for medication safety.

Monkman H, Kushniruk AW. Stud Health Technol Inform. 2017;234:233-237.

Medication management in outpatient settings requires patients to recognize adverse medication effects. This expert review study found that standardized information from a large Canadian retail pharmacy lacked key information about possible adverse effects and drug interactions. The authors suggest that this information gap leads to an urgent and addressable patient safety risk.

Journal Article > Commentary

Ethical dilemma in missed melanoma: what to tell the patient and other providers.

Vangipuram R, Horner ME, Menter A. J Am Acad Dermatol. 2017;76:365-367.

Despite the emphasis on open discussion of errors as a component of transparency, clinicians remain reluctant to disclose the errors of their peers to patients. This commentary discusses an incident involving a diagnosis of melanoma missed during the initial examination with a podiatrist that was later detected during a dermatology evaluation and describes how to manage such conversations between the providers as well as with the patient.

Cases & Commentaries

Safeguarding Diagnostic Testing at the Point of Care

  • Web M&M

Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD; February 2017

In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.

Journal Article > Study

Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation.

  • Classic

Kostopoulou O, Porat T, Corrigan D, Mahmoud S, Delaney BC. Br J Gen Pract. 2017;67:e201-e208.

Improving diagnosis in outpatient care is a patient safety priority. This simulation study evaluated the process of diagnosis in the primary care setting. Investigators contrasted physicians' diagnostic accuracy conducting a primary care visit in their usual manner versus using a clinical decision support tool. Each visit employed a standardized patient (an actor reporting symptoms consistent with a given diagnosis) and the visits with and without decision support were matched for complexity. The tool improved diagnostic accuracy significantly: 68% of visits using decision support reached the correct diagnosis versus 59% of usual care visits. The duration of visits and number of subspecialty consultations did not change with or without decision support. Physician participants rated the usability of the decision support tool favorably overall. These data suggest that decision support can be feasibly integrated into primary care to improve diagnostic accuracy.

Journal Article > Study

Electronic detection of delayed test result follow-up in patients with hypothyroidism.

Meyer AND, Murphy DR, Al-Mutairi A, et al. J Gen Intern Med. 2017;32:753-759.

Trigger tools facilitate identification of adverse events. In this retrospective medical record review study, investigators found that an automated trigger successfully identified delayed follow-up of laboratory thyroid testing among patients with hypothyroidism, with a positive predictive value of 60%. The authors suggest that this trigger approach could be used to detect and ameliorate follow-up delays in real time.

Journal Article > Study

Reevaluation of diagnosis in adults with physician-diagnosed asthma.

Aaron SD, Vandemheen KL, FitzGerald JM, et al; Canadian Respiratory Research Network. JAMA. 2017;317:269-279.

Misdiagnosis can contribute to overuse of unnecessary medication and treatments as well as a delay in appropriate treatment, placing patients at increased risk of harm. This prospective cohort study suggests that asthma may be frequently misdiagnosed in the community setting as a result of inadequate testing for airflow limitations. In 2% of the cases analyzed, a serious underlying cardiorespiratory condition was misdiagnosed as asthma.

Journal Article > Study

Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis.

Rees P, Edwards A, Powell C, et al. PLoS Med. 2017;14:e1002217.

Since the inception of the patient safety movement, most research has focused on the inpatient setting. Although the focus on ambulatory safety has grown in recent years, little is known about adverse events in outpatient pediatric care. In this mixed methods study, researchers analyzed incident reports involving sick pediatric primary care patients from the England and Wales' National Reporting and Learning System over a 9-year period. Using descriptive and thematic analysis, researchers sought to identify the most common and serious event types, reasons these events occurred, and opportunities for improving safety. They found that about one third of 2191 safety incidents represented cases of severe harm. Based on their analysis, the authors conclude that efforts should focus on building safer systems for medication dispensing in community pharmacies, enhancing the triage process for sick children, and improving communication between providers and parents. An accompanying editorial discusses the value of incident reports with regard to improving care for pediatric primary care patients.

Journal Article > Study

E-prescribing and adverse drug events: an observational study of the Medicare Part D population with diabetes.

Gabriel MH, Powers C, Encinosa W, Bynum JP. Med Care. 2017;55:456-462.

Hypoglycemia is a common and severe adverse drug event among patients with diabetes. This retrospective study of claims data found that Medicare patients with diabetes were less likely to be hospitalized or seen in the emergency department for hypoglycemia if their medications were prescribed electronically, compared to those receiving fewer or no electronic prescriptions. These findings add to the literature demonstrating the benefits of electronic prescribing.

Journal Article > Study

Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures.

  • Classic

Weingart SN, Stoffel EM, Chung DC, et al. Jt Comm J Qual Patient Saf. 2017;43:32-40.

Delayed cancer diagnosis is a critical patient safety concern in primary care. Rectal bleeding is an important issue to recognize promptly, because it may be a symptom of colon cancer, for which delayed diagnosis can lead to worse outcomes. For this retrospective study, physician reviewers examined 438 abstracted medical records of patients with rectal bleeding to identify problems in the diagnostic process. In the majority of cases, they identified problems such as failure to elicit sufficient family history, incomplete physical examination performance or documentation, and lack of needed laboratory testing. Consistent with prior studies, failure to order laboratory testing and plan follow-up were associated with worse care quality. These findings emphasize the challenges of achieving timely and accurate diagnosis in the outpatient setting. In a related editorial, Hardeep Singh suggests that enhancing electronic health record capability and trigger tools could address diagnostic delays in primary care.

Cases & Commentaries

Continuity Errors in Resident Clinic

  • Web M&M

Eric Warm, MD; November 2016

After a motor vehicle collision, a patient with headaches and difficulty concentrating visited the internal medicine clinic. The covering resident diagnosed postconcussive syndrome and prescribed amitriptyline. The patient returned several days later with persistent symptoms. She saw a different resident, who ordered an MRI and referred her to neurology but mistakenly made the referral to the neuromuscular, rather than headache, clinic. With continued severe headaches, the patient returned a third time and saw her primary resident provider, who referred her to the correct neurology clinic.

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