Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Active Errors"

1 - 20 of 190 results
Download Selected Citations

Show: 20 | 50 | 100

Meeting/Conference > Massachusetts Meeting/Conference

Improving Patient Safety With Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 26–27, 2017; Constellation Energy Building, Baltimore, MD.

This two-day workshop will discuss of how human factors engineering methods can be applied to identify risks, augment the work environment, and evaluate technology to address potential system failures in health care. 

Cases & Commentaries

Diagnostic Overshadowing Dangers

  • Web M&M

Maria C. Raven, MD, MPH, MSc; June 2017

Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.

Journal Article > Study

Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.

Sparks JL, Crouch DL, Sobba K, et al. JAMA Surg. 2017 May 24; [Epub ahead of print].

Multiple studies have linked poor teamwork and communication to adverse events in the operating room. There is a growing recognition that surgeons must learn these nontechnical skills during training in addition to the traditional focus on technical ability. In this controlled study, surgical residents participated in an educational intervention (a simulated surgical emergency) that simultaneously targeted technical and nontechnical skill development. The study used two different types of simulation—high fidelity (a cadaver) and medium fidelity (an anatomically correct mannequin)—compared to a control group, which used a nonanatomic simulator. Investigators found that nontechnical skills improved in both intervention groups compared to the control group, measured using validated teamwork assessments. As the accompanying editorial notes, the study findings indicate that technical and nontechnical skills may be best taught together, as teamwork skills improved when residents also had to perform a simulated surgical task simultaneously.

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

We are going to name names and call you out! Improving the team in the academic operating room environment.

Bodor R, Nguyen BJ, Broder K. Ann Plast Surg. 2017;78(suppl 4):S222-S224.

This study of operating room teams found that nursing staff, attending surgeons, and anesthesiologists did not always know the name or postgraduate year rank of trainees participating in surgery with them. The authors describe this lack of familiarity with team members as a knowledge gap that has the potential to affect surgical safety.

Journal Article > Commentary

Learning and mindfulness: improving perioperative patient safety.

Graling PR, Sanchez JA. AORN J. 2017;105:317-321.

The surgical environment is complex, and strategies to address human error and learn from mistakes are important to improve safety in this setting. This commentary discusses how organizational learning and mindfulness can help perioperative staff manage and prevent missteps in the operating room.

Journal Article > Study

Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study.

Prakash S, Bihari S, Need P, Sprick C, Schuwirth L. BMC Med Educ. 2017;17:36.

Cognitive bias can lead to diagnostic error. To better understand the prevalence of cognitive error among first-year residents, interns were observed as they handled acute clinical problems during simulation sessions. Researchers found a high prevalence of cognitive error, which did not change over time and adversely affected clinical performance.

Journal Article > Study

Learning through experience: influence of formal and informal training on medical error disclosure skills in residents.

Wong BM, Coffey M, Nousiainen MT, et al. J Grad Med Educ. 2017;9:66-72.

Error disclosure is universally recommended but incompletely implemented. Comparing disclosure skills among residents who completed experiential training to a historical cohort, this study found that current residents performed better. These results indicate that safety culture with respect to disclosure may be improving over time.

Book/Report

Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.

McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.

This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.

Journal Article > Commentary

Teaching the diagnostic process as a model to improve medical education.

Sklar DP. Acad Med. 2017;92:1-4.

Medical education has evolved to teach learners about improving patient safety. This commentary explores how relationships between patients, families, and physicians could help reduce diagnostic error and discusses the importance of providing education about clinical decision-making.

Journal Article > Commentary

Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error.

Ruedinger E, Olson M, Yee J, Borman-Shoap E, Olson APJ. Am J Med Qual. 2016 Nov 29; [Epub ahead of print].

Diagnostic error has yet to be formally integrated into graduate medical education. This commentary describes the design, implementation, and evaluation of a resident curriculum on diagnostic errors that explored medical decision making, critical thinking skills, and how to provide feedback and support for second victims.

Journal Article > Commentary

Overdiagnosis of coronary artery disease detected by coronary computed tomography angiography: a teachable moment.

Schmidt T, Maag R, Foy AJ. JAMA Intern Med. 2016;176:1747-1748.

Overdiagnosis can result in financial, psychological, and physical harm to patients. This commentary discusses how a communication gap left a patient uninformed about the risks associated with an invasive cardiac procedure that was later found to be unnecessary.

Cases & Commentaries

Unintended Consequences of CPOE

  • Spotlight Case
  • CME/CEU
  • Web M&M

Robert L. Wears, MD, PhD; October 2016

While attempting to order a CT scan with only oral contrast for a patient with poor kidney function, an intern ordering a CT for the first time selected "with contrast" from the list, not realizing that meant both oral and intravenous contrast. The patient developed contrast nephropathy.

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.

Newspaper/Magazine Article

A better safety net for young doctors.

Landro L. Wall Street Journal. August. 8, 2016.

First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.

Journal Article > Review

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.

Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.

Journal Article > Study

Using simulation to improve first-year pharmacy students' ability to identify medication errors involving the top 100 prescription medications.

Atayee RS, Awdishu L, Namba J. Am J Pharm Educ. 2016;80:86.

Pharmacists can intercept prescription errors before they reach patients. This study found that an educational intervention that combined didactic lecture and simulation methods enhanced first-year pharmacy students' ability to identify prescribing errors. These results demonstrate the value of developing pharmacy education to improve patient safety.

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

Raising awareness of cognitive biases during diagnostic reasoning.

van Geene K, de Groot E, Erkelens C, Zwart D. Perspect Med Educ. 2016;5:182-185.

This educational intervention found that students were less likely to reach the correct diagnosis for a written case when a salient distracting feature was present, and this experience of missed diagnosis made them more accepting of the concept of cognitive bias. This demonstrates the need for experiential learning to foster diagnostic accuracy.

Journal Article > Review

Systematic review and meta-analysis of educational interventions designed to improve medication administration skills and safety of registered nurses.

Härkänen M, Voutilainen A, Turunen E, Vehviläinen-Julkunen K. Nurse Educ Today. 2016;41:36-43.

Adverse drug events can result from errors in medication administration by nurses. This meta-analysis found that a broad range of nursing education interventions, from simulation to traditional didactic curricula, can improve the safety of medication administration. This suggests that multiple nursing educational strategies can be used to enhance inpatient medication safety.

Back to Top