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Approach to Improving Safety
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Search results for "Active Errors"

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Newspaper/Magazine Article

The last person you'd expect to die in childbirth.

Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.

Maternal mortality is increasing in the United States. This news article reports on this critical safety problem in the context of the preventable death of a patient whose diagnosis of preeclampsia was missed by her providers, despite persistent concerns raised by family about the patient's symptoms.

Newspaper/Magazine Article

A lost voice.

Baker M. Seattle Times. February 10, 2017.

Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.

Journal Article > Study

All consumer medication information is not created equal: implications for medication safety.

Monkman H, Kushniruk AW. Stud Health Technol Inform. 2017;234:233-237.

Medication management in outpatient settings requires patients to recognize adverse medication effects. This expert review study found that standardized information from a large Canadian retail pharmacy lacked key information about possible adverse effects and drug interactions. The authors suggest that this information gap leads to an urgent and addressable patient safety risk.

Newspaper/Magazine Article

Misdiagnoses: a hidden risk of genetic testing.

Howard J. CNN. October 31, 2016.

Although genetic testing can provide proactive assessment for disease, it can also result in unnecessary care. This news article reports on the unexpected death of a child and how the family experienced psychological harm and received unnecessary care due to misdiagnosis related to false positive test results for long QT syndrome.

Newspaper/Magazine Article

More than half a million heart surgery patients at risk of a dangerous infection.

Sun LH. The Washington Post. October 13, 2016.

Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.

Newspaper/Magazine Article

Sick children face potentially deadly danger: medication errors.

Furfaro H. Wall Street Journal. September 25, 2016.

Medication errors in pediatric care are common in the hospital and at home. This newspaper article reports on problems associated with medication safety among pediatric patients and highlights several tools both clinicians and parents can use to enhance safety when administering medicine to children, including dosage calculators and pictures depicting medication administration processes.

Newspaper/Magazine Article

When doctors get the wrong patient.

Whitman E. Mod Healthc. September 25, 2016.

Misidentification of patients can result in problems such as medication administration delays, blood transfusion mismatches, and wrong-patient surgery. This magazine article reviews recent research on this issue and suggests several system approaches for improvement, including the use of patient photos in electronic health records and standardizing patient identification processes.

Tools/Toolkit > Fact Sheet/FAQs

Four Medication Safety Tips for Older Adults.

FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; September 20, 2016.

Highlighting how aging affects medication absorption that may lead to complications, this fact sheet offers recommendations for older patients to follow instructions, maintain a medication list, be aware of drug interaction potential, and perform an annual review of medications with clinicians to help them take prescriptions safely.

Journal Article > Commentary

Performing the wrong procedure.

Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.

Describing an incorrect procedure incident which involved placement of a dialysis catheter instead of a central line, this commentary outlines the root causes of the event and how it could have been prevented. A related editorial introduces Performance Improvement, a series of case-based articles intended to support frontline performance improvement efforts.

Newspaper/Magazine Article

Surviving a bad diagnosis.

Hobson K. US News News and World Report. September 13, 2016.

Diagnostic error has recently gained recognition as an important patient safety concern. This news article relates the experiences of patients who were misdiagnosed and discusses avenues for improvement such as exploring physician problem-solving behaviors and using trigger tools to detect potential lapses in care.

Journal Article > Study

Liquid medication errors and dosing tools: a randomized controlled experiment.

Yin HS, Parker RM, Sanders LM, et al. Pediatrics. 2016;138:e20160357.

Misinterpretation of medication labels is a well-recognized source of medication error in the outpatient setting, especially among patients with low health literacy. This randomized controlled study looked at how units of measurement on medication labels and dosing tool characteristics affected dosing errors with regard to liquid medications in pediatrics. About 84% of parents made at least one dosing error, and 21% made at least one large error, defined as administering more than double the dose. Researchers concluded that the use of oral syringes resulted in fewer dosing errors than cups, especially when administering small doses. The authors conclude that oral syringes should be recommended when dispensing liquid medications in pediatrics. A prior WebM&M commentary discussed a pediatric dosing error.

Newspaper/Magazine Article

Medical misdiagnoses put pressure on patients to stay engaged.

Innes S. Arizona Daily Star. September 12, 2016.

Delayed diagnoses can have serious consequences. This news article reviews several examples of misdiagnosis and insights from the patients and families involved, explores the importance of engaging patients in determining correct diagnoses, and places the discussion in the broader context of efforts to reduce diagnostic error.

Cases & Commentaries

A Pill Organizing Plight

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

Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016

An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.

Audiovisual

Making health care safer. Think sepsis. Time matters.

CDC Vital Signs. August 23, 2016.

Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

Newspaper/Magazine Article

5 cataract surgeries, 5 people blinded: what went wrong?

Kowalczyk L. Boston Globe. August 14, 2016.

Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.

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 > 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.

Newspaper/Magazine Article

Paralyzed by errors, this Xbox designer is taking on hospital safety.

Aleccia J. Seattle Times. June 18, 2016.

Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.

Newspaper/Magazine Article

When a surgeon should just say 'I'm sorry'.

Cohen E. CNN. March 24, 2016.

Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.

Newspaper/Magazine Article

Fatal mistakes.

Kliff S. Vox Media. March 15, 2016.

Health professionals involved in medical errors experience psychological stress, which can have serious consequences if they are unable to cope with their mistake. Reporting on the second victim phenomenon, this news article discusses a well-known incident that led to the suicide of a nurse, how insufficient organizational and peer support systems affect clinicians, initiatives to provide counseling in similar situations, and the need for more universal change.

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