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Approach to Improving Safety
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Search results for "Active Errors"

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Newspaper/Magazine Article

Rude providers jeopardize patient safety. So stop it.

Thew J. HealthLeaders Media. June 14, 2017.

Rudeness can affect teamwork and hinder safe, transparent care. This news article reports on one hospital's approach to manage disruptive behavior through strategies such as peer identification and proactive behavior adjustment.

Patient Safety Primers

Falls

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

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.

Newspaper/Magazine Article

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.

Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.

Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Journal Article > Study

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

Martinez W, Lehmann LS, Thomas EJ, et al. BMJ Qual Saf. 2017 Apr 25; [Epub ahead of print].

Health care provider comfort with raising patient safety concerns is a critical aspect of safety culture. This survey of resident physicians at six academic medical centers demonstrated that trainees remain reluctant to speak up. Nearly half reported observing a patient safety threat. The majority spoke up about patient safety concerns, but a significant proportion did not. Although unprofessional behavior was more frequently observed, fewer trainees raised concerns about lack of professionalism than about patient safety. Even when respondents perceived the unprofessional behavior as having high potential for adverse patient consequences, they were not as likely to speak up about this compared to a traditional patient safety threat such as inadequate hand hygiene. The authors recommend specifically measuring tolerance for unprofessional behaviors as a part of safety culture assessment.

Journal Article > Study

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.

Sharma M, Krishnamurthy M, Snyder R, Mauro J. Clin Pract. 2017;7:953.

Anticoagulants are considered high-risk medications due to their narrow therapeutic window and association with adverse drug events. This study suggests that integration of a clinical pharmacist into the inpatient team may help prevent anticoagulation dosing errors and resultant harm to patients.

Journal Article > Study

Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992–2014.

Schaffer AC, Jena AB, Seabury SA, Singh H, Chalasani V, Kachalia A. JAMA Intern Med. 2017;177:710-718.

This retrospective study of a claims database found that medical malpractice claims declined significantly between 1992 and 2014, but mean payment amounts increased at the same time. Diagnostic error was the overall most common reason for a claim, affirming the importance of improving diagnosis.

Journal Article > Review

A systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics.

Alabdali A, Fisher JD, Trivedy C, Lilford RJ. Air Med J. 2017;36:116-121.

Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.

Audiovisual

The War on Error: Common Diagnostic Errors.

Medscape. 2016–2017.

Improving diagnosis has recently been recognized as a primary focus for patient safety. This collection highlights particular clinical areas of concern such as neurology and infectious disease. The articles offer expert commentary and review strategies to avoid common reasoning errors.

Journal Article > Commentary

A learning health care system using computer-aided diagnosis.

Cahan A, Cimino JJ. J Med Internet Res. 2017;19:e54.

Although advanced computing can assist in diagnosis, these systems are not routinely utilized. This commentary suggests a framework to develop diagnostic support technologies that capture physician knowledge to enhance diagnostic safety. The authors encourage drawing from crowdsourced data to guide improvements at a system level to address future practice and educational needs.

Perspectives on Safety > Annual Perspective

Measuring and Responding to Deaths From Medical Errors

with commentary by Sumant Ranji, MD, 2016

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

Journal Article > Study

Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database.

Poudel DR, Acharya P, Ghimire S, Dhital R, Bharati R. Pharmacoepidemiol Drug Saf. 2017;26:635-641.

Analyzing data from the AHRQ Healthcare Cost and Utilization Project, this study found that hospitalizations related to adverse drug events increased from 2008 to 2011. These hospitalizations are common and costly, and they demonstrate higher odds of in-hospital death. These data underscore the urgent need to enhance medication safety.

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 > Study

Learning from errors: analysis of medication order voiding in CPOE systems.

Kannampallil TG, Abraham J, Solotskaya A, et al. J Am Med Inform Assoc. 2017 Feb 17; [Epub ahead of print].

Although computerized provider order entry has been found to prevent some medication errors, simulation studies have also demonstrated that electronic prescribing platforms can introduce or fail to prevent medication errors. This retrospective electronic health record analysis examined medication orders that were canceled. Weekend and overnight orders were less likely to be voided than weekday or daytime orders. Pharmacist, nurse, and student orders were more likely to be canceled than physician orders. Comparing the clinician-provided reason for voiding an order with the more comprehensive information in the medical record, physicians found that clinicians' reported reasons for voiding orders were largely inaccurate. The authors suggest there is unrealized potential to characterize medication ordering errors using voided-order data.

Journal Article > Commentary

The CARE approach to reducing diagnostic errors.

Rush JL, Helms SE, Mostow EN. Int J Dermatol. 2017;56:669-673.

Cognitive aids such as checklists and mnemonics can improve process reliability. This project report discusses the development of a mnemonic focused on avoiding diagnostic errors. The authors used the CARE mnemonic (communicate, assess for biased reasoning, reconsider differential diagnoses, enact a plan) as an instruction model to reduce diagnostic errors in their practice.

Journal Article > Study

Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications.

  • Classic

Cooper WO, Guillamondegui O, Hines OJ, et al. JAMA Surg. 2017;152:522-529.

Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.

Journal Article > Commentary

Responsible e-prescribing needs e-discontinuation.

Fischer S, Rose A. JAMA. 2017;317:469-470.

E-prescribing is a key strategy to improve medication safety by addressing illegible prescriptions, order omissions, and dosage confusion. However, there have been unintended consequences such as the inability to discontinue medications ordered electronically. This commentary reviews problems associated with this unintended consequence and suggests that enabling electronic cancellation of prescriptions can help address the issue. A WebM&M commentary discussed a case involving an electronic prescribing error.

Journal Article > Review

Managing the patient identification crisis in healthcare and laboratory medicine.

Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Clin Biochem. 2017;50:562-567.

Patient identification mistakes associated with diagnostic blood testing can have serious consequences. This commentary recommends several strategies to redesign laboratory processes to reduce risks of specimen misidentification, such as utilizing at least two patient identifiers, providing staff training, and using technologies to track and manage specimens.

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.

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