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Search results for "Active Errors"

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Meeting/Conference > Kansas Meeting/Conference

Second Victim Train-the-Trainer Workshop.

Center for Patient Safety and University of Missouri. November 10, 2017; Saint Luke's North Hospital, Barry Road, Kansas City, MO.

Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies to build an organizational program that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.

Meeting/Conference > Massachusetts Meeting/Conference

Patient Safety and Healthcare Quality Improvement 2017.

Harvard Medical School. October 16-17, 2017; Sheraton Boston Hotel, Boston, MA.

This workshop offers insights from safety leaders about applying strategies and guidelines to quality and safety improvement in the acute care setting. This conference has expanded its scope beyond clinicians and patient safety officers to provide educational resources for pharmacists and nurses. Keynote speakers include James Conway and Dr. Thomas H. Lee.

Meeting/Conference > Massachusetts Meeting/Conference

Diagnostic Error in Medicine 10th International Conference.

Society to Improve Diagnosis in Medicine. October 8-10, 2017, Boston Marriott Newton, Newton MA.

This annual conference will focus on the theme, "Improving Diagnosis: It Takes a Team" to drive work in reducing diagnostic errors. Featured speakers include Dr. Donald Berwick, Professor Amy Edmondson and Dr David Mayer.

Meeting/Conference > Government Resource

AHRQ Research Summit on Improving Diagnosis in Health Care.

Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.

Research is increasingly focusing on diagnostic errors and strategies to reduce them. This conference explored the science behind diagnosis and discuss the research, tactics, and tools needed to enhance diagnostic performance.

Cases & Commentaries

Complaints as Safety Surveillance

  • Web M&M

Jennifer Morris and Marie Bismark, MD; September 2016

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Journal Article > Commentary

JAMA professionalism: disclosure of medical error.

  • Classic

Levinson W, Yeung J, Ginsburg S. JAMA. 2016;316:764-765.

Disclosing medical errors to patients is essential for maintaining a therapeutic relationship and preventing further harm. This commentary describes a case in which a physician inadvertently used nonsterile instruments to perform procedures on two patients and presents options for what the physician might do next. Recommended best practices for error disclosure include being honest about what happened, explicitly stating that an error occurred, and explaining to the patient any relevant specific information that might be helpful in terms of necessary follow-up. The authors suggest that all errors be formally reviewed to prevent future harm and that health care systems should create an environment that facilitates error reporting.

Journal Article > Review

The global burden of diagnostic errors in primary care.

Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. BMJ Qual Saf. 2017;26:484-494.

The need to improve diagnosis is gaining international recognition. This review summarizes the literature on diagnostic error in primary care and recommends policy and research strategies to prioritize changes needed to enhance diagnostic safety globally.

Journal Article > Commentary

Incorporating indications into medication ordering—time to enter the age of reason.

Schiff GD, Seoane-Vazquez E, Wright A. N Engl J Med. 2016;375:306-309.

Clear communication during medication prescribing can enhance safety. This commentary advocates for indications-based prescribing coupled with health information technology as a way to improve team communication, medication reconciliation, and patient education and compliance.

Journal Article > Review

Situational awareness—what it means for clinicians, its recognition and importance in patient safety.

Green B, Parry D, Oeppen RS, Plint S, Dale T, Brennan PA. Oral Dis. 2016 Jul 22; [Epub ahead of print].

Situational awareness during critical incidents is a key component of teamwork. This review spotlights the importance of situational awareness in health care and provides information about how to assess and develop it in individual clinicians and among team members.

Journal Article > Study

Boosting medical diagnostics by pooling independent judgments.

Kurvers RHJM, Herzog SM, Hertwig R, et al. Proc Natl Acad Sci U S A. 2016;113:8777-8782.

Diagnostic error remains a significant source of preventable patient harm. Because bias on the part of health care providers can contribute to diagnostic errors, improving the medical decision-making process may serve as an error prevention strategy, possibly through the use of collective intelligence. This study sought to better understand the conditions under which collective intelligence might augment medical judgment. Using large data sets consisting of more than 140 doctors and 20,000 diagnoses, the investigators determined that when providers have similar individual diagnostic accuracy rates, pooling their judgments improves decision accuracy. However, if accuracy levels vary across providers, pooling independent judgment leads to worse diagnostic outcomes. The authors suggest that similar diagnostic accuracy should be a key condition when creating groups for the purpose of improving medical diagnosis. A previous WebM&M commentary discussed a case of diagnostic error.

Journal Article > Commentary

Case report of a medication error: in the eye of the beholder.

Naunton M, Nor K, Bartholomaeus A, Thomas J, Kosari S. Medicine (Baltimore). 2016;95:e4186.

Look-alike drug names or packaging are known to contribute to medication errors. This case discussion reviews an error in the community setting involving a nonocular medication mistakenly administered as an eye drop due to look-alike packaging and recommends ways to improve storage and disposal processes to avoid similar incidents.

Journal Article > Commentary

Guideline implementation: prevention of retained surgical items.

Fencl JL. AORN J. 2016;104:37-48.

Although incidents involving retained surgical items are rare, they continue to occur. This commentary reviews guidance for perioperative nurses to reduce risks of this sentinel event. The author outlines steps to improve safety such as team accountability, standardized surgical sponge counts, and reconciling count discrepancies.

Tools/Toolkit > Fact Sheet/FAQs

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

Horsham, PA: Institute of Safe Medication Practices; 2016.

Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.

Journal Article > Study

Standardization of compounded oral liquids for pediatric patients in Michigan.

Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.

When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.

Journal Article > Study

Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.

Yadav S, Kazanji N, Narayan KC, et al. J Am Med Inform Assoc. 2017;24:140-144.

Compared to paper charts, electronic health records offer safety benefits for physician documentation including better availability and legibility. However, electronic documentation introduces new concerns, such as copy-and-paste practices (which can perpetuate errors) and lack of diagnostic reasoning in electronic notes. This study compared physical exam documentation in initial physician progress notes before and after implementation of an electronic health record. Investigators found more inaccuracies in electronic notes, but more errors of omission in paper charts. Trainee physicians' documentation had fewer errors in both paper and electronic formats. The authors recommend that hospitals discourage copied notes and encourage accurate documentation at the time of the patient encounter. The importance of the physical examination itself was discussed in a PSNet interview with Dr. Abraham Verghese.

Journal Article > Commentary

The problem with root cause analysis.

Peerally MF, Carr S, Waring J, Dixon-Woods M. BMJ Qual Saf. 2017;26:417-422.

Root cause analysis (RCA) is a strategy to investigate incidents that has gained acceptance in health care. Discussing weaknesses associated with using RCAs, this commentary suggests that challenges such as inappropriate focus on single-point causation, poor analysis quality, and insufficient feedback should be addressed to enhance the effectiveness of RCAs and sustain organizational learning from failure.

Journal Article > Study

Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.

Elmore JG, Tosteson AN, Pepe MS, et al. BMJ. 2016;353:i3069.

This study found that eliciting second opinions in pathology improved the accuracy of breast histopathology specimens. This work provides further evidence that diagnostic accuracy can be enhanced with second opinions. The authors suggest that implementing multiple clinician review may augment the diagnostic process.

Journal Article > Study

Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.

Langer T, Martinez W, Browning DM, Varrin P, Sarnoff Lee B, Bell SK. BMJ Qual Saf. 2016;25:615-625.

Health systems struggle with how to effectively involve patients in safety efforts without placing undue responsibility or blame on them. Greater patient–clinician collaboration is particularly important for error disclosure because of the well-documented gaps in clinician and patient perspectives. In this study, investigators developed an intervention to have patients or family members teach error disclosure and prevention to interprofessional clinician learners, including physicians, nurses, and social workers. Their pre–post evaluation showed that the majority of patient and clinician participants reported improved communication and found the intervention valuable. Patient and clinician participation was voluntary. Although these results show promise for involving patients and families as teachers for error disclosure and prevention training, further work is needed to determine whether this approach will be effective among broader health care teams, as opposed to interested clinicians who volunteer. A related editorial discusses the challenges of including patients in safety efforts.

Journal Article > Study

Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens.

Tong EY, Roman C, Mitra B, et al. J Clin Pharm Ther. 2016;41:414-418.

Medication discrepancies during hospital admission are common and can lead to preventable harm. This study examined the impact of having a pharmacist review medical charts of patients with complex medication regimens who were admitted to a general medical or emergency short-stay unit. The authors found that partnering medical staff with a pharmacist to review patients' admission medications in the chart significantly decreased inpatient medication errors.

Tools/Toolkit > Fact Sheet/FAQs

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

Institute for Safe Medication Practices. June 2016.

Mistakes associated with look-alike medication names are a safety concern in health care. Tall Man lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of Tall Man lettering to make their use safer.

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