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Approach to Improving Safety
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Search results for "Active Errors"

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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 > Study

Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.

Lauritzen PM, Andersen JG, Stokke MV, et al. BMJ Qual Saf. 2016;25:595-603.

Repeat interpretation of radiological images is known to yield more accurate diagnosis. Investigators interpreted more than 1000 abdominal CT scans twice and found clinically significant changes on the second read in 14% of cases. The authors suggest that using expert second radiology interpretation may enhance diagnostic accuracy.

Journal Article > Commentary

Disclosure of medical errors involving gametes and embryos.

Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.

This publication advocates for open disclosure of errors in reproductive medicine.

Journal Article > Study

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

Hughes KM, Goswami ES, Morris JL. J Pediatr Pharmacol Ther. 2015;20:453-461.

Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.

Journal Article > Commentary

Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.

Cerniglia-Lowensen J. J Radiol Nurs. 2015;34:4-7.

Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its value as a safety improvement strategy.

Journal Article > Commentary

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2015;122:495-520.

This practice advisory summarizes the literature and expert opinion to advise practitioners on the dangers of administering anesthesia to patients receiving magnetic resonance imaging, or MRIs.

Cases & Commentaries

Bowel Injury After Laparoscopic Surgery

  • Web M&M

Krishna Moorthy, MD, MS; January 2015

Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.

Journal Article > Commentary

Unintended side effects: arbitration and the deterrence of medical error.

Shieh D. N Y Univ Law Rev. 2014;89:1806-1835.

This commentary explores the role of medical malpractice arbitration as a deterrent to medical error. The author suggests that although shifting from litigation to arbitration could result in improved efficiency and accuracy regarding medical malpractice litigation, it is not proven as a strategy to deter error. The discussion draws from the experience of a large health care system to recommend modifications in the arbitration process to prevent medical error.

Journal Article > Commentary

'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports.

Ratwani RM, Fong A. J Am Med Inform Assoc. 2015;22:312-317.

This commentary describes the design and development of hospital-level and system-level dashboards representing data from patient safety event reporting systems as a way to reduce the burden of analyzing internal incident reports, increase awareness of adverse event trends, and enable utilization of the data to inform improvement.

Journal Article > Review

Hardwiring patient blood management: harnessing information technology to optimize transfusion practice.

Dunbar NM, Szczepiorkowski ZM. Curr Opin Hematol. 2014;21:515-520.

Mistakes during blood transfusion can contribute to patient harm. This review discusses the use of health information technology, such as computerized provider order entry and clinical decision support systems, in transfusion medicine to enhance reliability of ordering practices and enable monitoring of adherence.

Journal Article > Study

Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project.

Malicki J, Bly R, Bulot M, et al. Radiother Oncol. 2014;112:194-198.

This survey study found that safety practices for managing external beam radiotherapy vary among European countries. As with other safety concerns, adverse events are under-reported to voluntary reporting systems and root cause analysis of such incidents does not routinely occur. These results have clear implications for designing the planned intervention to improve the safety of external beam radiotherapy.

Journal Article > Study

A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors.

  • Classic

Sarkar U, Simchowitz B, Bonacum D, et al. Jt Comm J Qual Patient Saf. 2014;40:461-470.

Diagnostic errors are a common cause of patient harm in ambulatory care. Although such errors have often been ascribed to cognitive biases, this study highlights physicians' concerns that health system structures and communication are major drivers of delayed and missed diagnoses. Focus group discussions involving 25 outpatient physicians—primarily from internal and family medicine—identified multiple potential sources of diagnostic errors, including insufficient information availability, disjointed workflows, and poor communication among providers and with patients. This study underscores many overlapping issues that will need to be addressed to meaningfully enhance diagnostic accuracy. In a recent AHRQ WebM&M interview, Dr. Urmimala Sarkar, the lead author of this study, discussed patient safety in the ambulatory setting.

Legislation/Regulation > Sentinel Event Alerts

Managing risk during transition to new ISO tubing connector standards.

Sentinel Event Alert. August 20, 2014;(53):1-6.

The Joint Commission issues sentinel event alerts in response to significant emerging safety risks for events which carry high risk and require immediate action. This alert reports on new standards for tubing connectors to prevent injury from incorrect administration of therapeutic agents. New ISO (International Organization for Standardization) standards prevent one type of tubing (such as intravenous) to be incorrectly attached to a different delivery system (such as a feeding tube.) The Joint Commission recommends multidisciplinary review of existing tubing connectors, maintaining awareness of the possibility for incorrect connections, and preparing and adopting safety connectors as soon as they are available in late 2014. A past AHRQ WebM&M commentary describes an administration error due to incorrect tubing connection.

Journal Article > Study

Exploring the causes of junior doctors' prescribing mistakes: a qualitative study.

Lewis PJ, Ashcroft DM, Dornan T, Taylor D, Wass V, Tully MP. Br J Clin Pharmacol. 2014;78:310-319.

Prescribing-related errors are common among junior physicians. Analyzing trainee physicians' prescribing errors using the critical incident technique, researchers identified several underlying causes, including knowledge deficits and authority gradients.

Journal Article > Commentary

Diagnostic error: untapped potential for improving patient safety?

Groszkruger D. J Healthc Risk Manag. 2014;34:38-43.

Highlighting how uncertainty around identifying diagnostic errors hinders measuring its incidence and developing solutions, this commentary outlines methods to augment diagnostic safety including teamwork activities, establishing best practices, and utilizing decision support systems.

Journal Article > Study

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.

Hardmeier A, Tsourounis C, Moore M, Abbott WE, Guglielmo BJ. J Healthc Qual. 2014;36:54-63.

After implementation of a barcode medication administration system at a children's hospital, adherence to institutional medication safety protocols was high and the incidence of medication administration errors appeared to be low based on direct observation.

Newspaper/Magazine Article

The role of failure mode and effects analysis in health care.

Fibuch E, Ahmed A. Physician Exec. Jul-Aug 2014;40:28-32.

Failure mode and effects analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system flaws. This article reviews the initial purpose of FMEA, provides a breakdown of the process, describes a scoring tool applying Six Sigma designations to determine probability of failure, and discusses how FMEA is used in health care settings.

Journal Article > Study

Wrong-side thoracentesis: lessons learned from root cause analysis.

Miller KE, Mims M, Paull DE, et al. JAMA Surg. 2014;149:774-779.

Wrong-site procedures result in significant patient harm, and prior studies have shown that—contrary to traditional assumptions—many of these errors occur outside the operating room. This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified several common themes in these errors. The majority of errors resulted in serious patient injury. Root cause analysis of the errors found that clinicians often failed to perform a time out and did not correctly document laterality in consent forms and clinical records. A case of a wrong-side thoracentesis that resulted in the death of a patient is discussed in a previous AHRQ WebM&M commentary.

Journal Article > Commentary

A medication-based trigger tool to identify adverse events in pediatric anesthesiology.

Taghon T, Elsey N, Miler V, McClead R, Tobias J. Jt Comm J Qual Patient Saf. 2014;40:326-334.

This commentary describes the development of a trigger tool initiative to detect and record adverse events in pediatric anesthesiology. The process included identifying which medications to track, creating a search mechanism, implementing the tool, and disseminating the data.

Journal Article > Commentary

Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia.

Tjia I, Rampersad S, Varughese A, et al. Anesth Analg. 2014;119:122-136.

This commentary provides an overview of root cause analysis methods and describes an initiative that educated its participants in these principles to enhance understanding of serious adverse events reported among collaborating institutions. The authors suggest that utilizing this approach can help proactively inform improvement activities.

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