Search results for "Active Errors"

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.

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.

An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.

The frequency of missed and delayed diagnoses is stimulating interest in innovative ways of improving the diagnostic process. This study reports on the initial experience of a crowdsourcing approach to diagnosis. Patients with difficult-to-diagnose symptoms accessed an online program where volunteer case solvers—only 58% of whom worked in medicine in any capacity—engaged in discussion with patients and provided diagnostic suggestions. A majority of patients felt the service was useful and about half would recommend the program.

Overprescribing can increase risk of dementia, particularly among older patients. This commentary describes an incident involving a patient with moderate dementia that worsened when opioids were prescribed following a fall. After a geriatrician evaluated the patient and suspected polypharmacy, the drugs were stopped, caregivers were educated about how to treat the patient, and the patient improved. Highlighting the importance of environmental interventions in treating this patient, the author reviews strategies to address neuropsychiatric symptoms of dementia.

Examining patient safety in home hospice care, the authors found that falls and inadequate symptom control (an error of omission) were the most common concerns, often related to patient or family caregiver actions rather than the home hospice team. This study reveals unique safety considerations around providing end-of-life care for patients.

Home care is one of the fastest growing sectors of the health care field, but recent research has raised safety concerns among patients receiving home services. A prospective cohort study revealed that 10% of home care patients experienced an adverse event, an incidence comparable to that found in hospitalized patients. This study used a Delphi approach to determine the types of adverse events in home care that should be considered serious (in terms of the level of patient harm) and preventable. Four types of serious preventable events were identified: inappropriate client service plans, medication errors requiring emergency treatment, catheter-associated infections, and incidents related to care that did not fall within practice standards. The authors advocate for using this classification scheme as the basis for a home care adverse event reporting system, analogous to state reporting systems for serious errors occurring in hospitalized patients.

Safety issues, particularly medication errors, are common in patients receiving home health care. This study suggests that electronic communication between physicians and home care nurses may improve medication safety.

This newspaper article reports on how transition coaches can help improve transfer and discharge communication to prevent readmissions.

This commentary describes how a medication administration error launched one organization's efforts to improve patient safety statewide.

This flyer provides tips to help prevent consumer medication errors.

Medication errors can be difficult to detect in ambulatory care, as patients or caregivers administer medications instead of health care providers. This descriptive study used home visits to children with chronic diseases to identify medication errors committed by parents, and found a remarkably high incidence of errors, particularly when parents did not use aids or support tools to help with medication administration. Although many errors were attributable to suboptimal provider–patient communication, physicians were unaware of errors in 80% of cases. An AHRQ WebM&M commentary discusses the effects of parental misunderstanding of medication instructions for their child.

This announcement alerts consumers and health care professionals to dangers associated with name confusion on a widely used over-the-counter medicine.

This video for consumers shares tips to avoid medication errors through improved communication, medication information review, and dosage measurement.

This study evaluated the prevalence of medication errors in community-dwelling elders and nursing home residents in Victoria, Australia.

This retrospective review of all exposures in children younger than 6 years found that H2-receptor antagonists and metoclopramide were the most common medication errors reported. Most of the dosing errors occurred at home and in children younger than 12 months.

This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child. 

The authors describe a method for identifying potential quality and safety problems in a care pathway.