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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.

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

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.

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.

Tools/Toolkit > Multi-use Website

Patient Safety Toolkit for General Practice.

London, UK: Royal College of General Practitioners; 2015.

Although most patient safety efforts have focused on inpatient care, the majority of health care actually takes place in the ambulatory setting. This toolkit for general practitioners in the United Kingdom provides various instruments to help prevent and analyze safety problems. Materials include a trigger tool, medication reconciliation form, and significant event audit template.

Journal Article > Study

Frequency of prescribing errors by medical residents in various training programs.

Honey BL, Bray WM, Gomez MR, Condren M. J Patient Saf. 2015;11:100-104.

Pediatric patients are at particularly high risk for medication errors. This study analyzed the prescribing error rate across residents in several training programs in an outpatient pediatric clinic. Somewhat surprisingly, senior residents were equally as likely as first-year residents to make prescribing errors.

Journal Article > Review

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use.

Kukreti V, Cosby R, Cheung A, Lankshear S; ST Computerized Prescriber Order Entry Guideline Development Group. Curr Oncol. 2014;21:e604-e612.

Medication error rates are extremely high among patients receiving outpatient chemotherapy. This systematic review found a paucity of studies on the effectiveness of computerized provider order entry (CPOE) in improving the safety of chemotherapy, but concluded that the limited evidence supports wider use of CPOE in this setting.

Journal Article > Study

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

Prakash V, Koczmara C, Savage P, et al. BMJ Qual Saf. 2014;23:884-892.

This study used high-fidelity simulation to evaluate the impact of several interventions on preventing medication administration errors by chemotherapy nurses. Interventions with a basis in human factors engineering principles appeared to be highly effective at reducing errors related to interruptions.

Newspaper/Magazine Article

What a doctor may miss by reaching for the MRI first.

Boodman SG, Kaiser Health News. Washington Post. May 19, 2014.

This newspaper article reports how lack of competency with performing physical examinations and over-reliance on technology can contribute to diagnostic errors and describes educational interventions to enhance medical students' diagnostic skills.

Journal Article > Study

The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations.

  • Classic

Singh H, Meyer AND, Thomas EJ. BMJ Qual Saf. 2014;23:727-731.

Diagnostic errors are increasingly recognized as a major source of preventable patient harm. Researchers compiled several studies to estimate the frequency of these errors in outpatient care across the United States. Two studies used a trigger approach to review unusual patterns of return visits in primary care and one study included consecutive lung cancer cases. From these data, the authors determined that approximately 5% of adults in the US, or more than 12 million individuals, experience a diagnostic error in the outpatient setting every year. This is the first study to evaluate the frequency of ambulatory diagnostic errors, and the results underscore the importance of efforts to improve diagnosis by addressing cognitive and systems vulnerabilities. A recent AHRQ WebM&M commentary describes a delayed diagnosis in outpatient care.

Cases & Commentaries

A "Reflexive" Diagnosis in Primary Care

  • Spotlight Case
  • Web M&M

John Betjemann, MD, and S. Andrew Josephson, MD; April 2014

Despite new back pain and worsening symptoms of tingling, pain, and weakness bilaterally, in both hands and feet, a man recently diagnosed with peripheral neuropathy was not sent for further testing after repeated visits to a primary care clinic. By the time neurologists saw him, they diagnosed critical cervical cord compression, which placed the patient at risk for permanent paralysis.

Cases & Commentaries

After-Visit Confusion

  • Web M&M

William Ventres, MD, MA; March 2014

A teenager presented to an urgent care clinic with new bumps and white spots near her tongue. Although she was diagnosed with herpetic gingivostomatitis, the after-visit summary incorrectly populated the diagnosis of "thrush" from the triage information, which was not updated with the correct diagnosis. The mistake on the printout caused confusion for the patient's mother and necessitated several follow-up communications to clear up.

Journal Article > Study

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

Singh R, Hickner J, Mold J, Singh G. J Patient Saf. 2014;10:20-28.

Unreliable test result management systems and failure to follow-up on abnormal test results are common issues in ambulatory care. Using a modified failure mode and effect analysis methodology, this study sought to prospectively identify safety hazards in the laboratory testing process in primary care clinics.

Tools/Toolkit > Fact Sheet/FAQs

Saying Sorry.

London, England: NHS Litigation Authority; 2013.

Although victims of adverse events have clearly expressed their preferences for full error disclosure, most physicians remain uncomfortable with disclosing and apologizing for errors. This leaflet offers information to help clinicians understand the value of effective apologies along with tips for organizations to support open disclosure efforts.

Journal Article > Review

Patient safety in the obstetric and gynecologic office setting.

Keats JP. Obstet Gynecol Clin North Am. 2013;40:611-623.

This review introduces a safety certification program for office-based obstetrics and gynecology. Key components of the program include hiring a medical director for patient safety, establishing a safety culture, improving communication with patients, and using checklists.

Journal Article > Review

Radiation protection and dose monitoring in medical imaging: a journey from awareness, through accountability, ability and action … but where will we arrive?

Frush D, Denham CR, Goske MJ, et al. J Patient Saf. 2013;9:232-238.

This review identifies technological advances in diagnostic imaging and outlines concerns that must be addressed to ensure safe radiation dosing.

Journal Article > Commentary

Improving patient safety through transparency.

Kachalia A. N Engl J Med. 2013;369:1677-1679.

This commentary describes successful transparency initiatives, identifies persistent barriers to discussing medical errors, and recommends strategies to promote disclosure in health care.

Book/Report

Stay Connected: FAQs about Small-Bore Connectors and Tubing Misconnections.

Arlington, VA: Association for the Advancement of Medical Instrumentation; October 2013.

To help prevent tubing misconnections, this toolkit offers frequently asked questions and corresponding answers about small-bore connectors.

Journal Article > Study

An initiative to improve the management of clinically significant test results in a large health care network.

Roy CL, Rothschild JM, Dighe AS, et al. Jt Comm J Qual Patient Saf. 2013;39:517-527.

Appropriate follow-up of abnormal test results remains a difficult issue. This local task force report recommends standardization of notification policies, clear identification of the care team, enhanced electronic result tracking, and quality reporting and metrics.

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