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Search results for "Active Errors"

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Cases & Commentaries

Communication Error in a Closed ICU

  • Web M&M

Barbara Haas, MD, PhD, and Lesley Gotlib Conn, PhD; May 2017

Admitted to the ICU with septic shock, a man with a transplanted kidney developed hypotension and required new central venous access. Since providers anticipated using the patient's left internal jugular vein catheter for re-starting hemodialysis (making it unsuitable to use for resuscitation), the ICU team placed the central line in the right femoral vein. However, they failed to recognize that his transplanted kidney was on the right side, which meant that femoral catheter placement on that side was contraindicated.

Journal Article > Review

Improving patient safety in handover from intensive care unit to general ward: a systematic review.

Wibrandt I, Lippert A. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

This systematic review of handoffs from intensive care to general ward identified eight intervention studies, none of which demonstrated improved mortality or lower readmission rates. Handoff strategies differed widely among the included studies. The authors recommend further study to identify best handoff practices for patients discharged from intensive care.

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.

Journal Article > Study

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

Wong A, Amato MG, Seger DL, et al. J Crit Care. 2017;39:156-161.

This retrospective study reviewed more than 47,000 overridden medication alerts and found that the vast majority of overrides were clinically appropriate and did not cause harm. From this sample, 7 adverse drug events were identified, and these events were more likely when the alerts were overridden in error. This study demonstrates the challenge of identifying clinically important alerts in a setting where alert fatigue is common.

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

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

Jones A, Johnstone MJ. Aust Crit Care. 2017;30:219-223.

This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.

Journal Article > Study

Impact of initial hospital diagnosis on mortality for acute myocardial infarction: a national cohort study.

Wu J, Gale CP, Hall M, et al. Eur Heart J Acute Cardiovasc Care. 2016 Aug 29; [Epub ahead of print].

Although diagnostic errors represent an important cause of preventable patient harm as well as a common and expensive source of malpractice litigation, they have received little attention until recently. Misdiagnosis or delayed diagnosis of common conditions, such as acute myocardial infarction (AMI), occurs frequently. In this study, researchers sought to assess whether a correct initial diagnosis had an impact on the mortality of patients with AMI. They looked at a cohort of patients over 9 years across 243 acute care hospitals in England and Wales with discharge diagnoses of ST-elevation myocardial infarction and non–ST-elevation myocardial infarction. The authors concluded that almost a third of patients were initially misdiagnosed and that this was associated with increased mortality. A PSNet Annual Perspective discussed recent advances in thinking about diagnostic error.

Journal Article > Study

Decreasing malpractice claims by reducing preventable perinatal harm.

Riley W, Meredith LW, Price R, et al. Health Serv Res. 2016;51(suppl 3):2453-2471.

Improving patient safety provides an opportunity to reduce malpractice claims and associated costs, particularly in higher risk clinical areas such as obstetrics. This study examined medical malpractice claims and cost data in the perinatal units of hospitals before and after implementation of safety interventions focused on decreasing perinatal harm. Interventions consisted largely of standardizing best practices and implementing team training. Investigators found that improving perinatal safety led to substantial reductions in both the frequency and total cost of malpractice claims. The role that the medical liability system plays in driving up health care costs and in promoting the practice of defensive medicine—which can lead to adverse events through unnecessary tests and procedures—was highlighted in a past WebM&M commentary.

Journal Article > Study

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

van Galen LS, Struik PW, Driesen BEJM, et al. PLoS One. 2016;11:e0161393.

Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.

Cases & Commentaries

Cognitive Overload in the ICU

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

Vimla L. Patel, PhD, and Timothy G. Buchman, PhD, MD; July/August 2016

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

Journal Article > Study

An observational study of adult admissions to a medical ICU due to adverse drug events.

Jolivot PA, Pichereau C, Hindlet P, et al. Ann Intensive Care. 2016;6:9.

Examining adverse drug events that led to admission to the intensive care unit, this study found that more than half of events were preventable. Non-compliance to medication, which leads to worsening of underlying conditions, was the most common cause of preventable adverse drug events.

Journal Article > Study

Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system.

Schulz CM, Krautheim V, Hackemann A, Kreuzer M, Kochs EF, Wagner KJ. BMC Anesthesiol. 2016;16:4.

This retrospective review of anesthesia and critical care cases in the German incident reporting system found that errors in situational awareness contributed to 81.5% of events. This study includes detailed examples and analyses of these errors, providing useful insights into lapses in situational awareness.

Journal Article > Review

Interruptions and medication administration in critical care.

Bower R, Jackson C, Manning JC. Nurs Crit Care. 2015;20:183-195.

Interruptions occur frequently during the medication process, and previous studies examined whether they increase risks. This review explores the literature on the impact of interruptions during medication administration to determine factors that contribute to interruptions and how to address them.

Journal Article > Review

Diagnostic errors in the pediatric and neonatal ICU: a systematic review.

Custer JW, Winters BD, Goode V, et al. Pediatr Crit Care Med. 2015;16:29-36.

Previous autopsy studies have found an error rate of nearly 9%, implying that thousands of patients die every year due to diagnostic errors. This systemic review of diagnostic errors in pediatric and neonatal intensive care unit (ICU) settings synthesized results of 13 studies of autopsies that confirmed diagnostic errors. The most common type of missed diagnosis found at autopsy was infection. Other prevalent missed diagnoses included vascular events and congenital conditions. The authors estimate that 6.4% of pediatric ICU deaths and 3.7% of neonatal ICU deaths are attributable to major missed diagnosis. This work argues for more prospective investigation of missed and delayed diagnoses as well as more routine autopsies in pediatric and neonatal ICU settings. A past AHRQ WebM&M commentary discussed the value of autopsies in understanding misdiagnoses.

Journal Article > Study

The effect of an electronic checklist on critical care provider workload, errors, and performance.

Thongprayoon C, Harrison AM, O'Horo JC, Sevilla Berrios RA, Pickering BW, Herasevich V. J Intensive Care Med. 2016;31:205-212.

Simulation has been advocated as a way to create a safe space to learn from error. This simulation-based study found that electronic checklists used by intensivists reduced workload and errors compared to paper checklists, adding to the evidence supporting checklist use in medical care.

Journal Article > Study

Error in intensive care: psychological repercussions and defense mechanisms among health professionals.

Laurent A, Aubert L, Chahraoui K, et al. Crit Care Med. 2014;42:2370-2378.

This interview study found that physicians and nurses experience guilt and shame following errors, echoing previous studies of the health care provider as the second victim in adverse events. A past AHRQ WebM&M interview with Dr. Albert Wu discusses the impact of errors on health care providers.

Journal Article > Study

Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.

Donaldson N, Aydin C, Fridman M, Foley M. J Healthc Qual. 2014;36:58-68.

This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.

Journal Article > Study

The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit.

Panesar RS, Albert B, Messina C, Parker M. Am J Med Qual. 2016;31:64-68.

Use of a structured communication tool within an electronic medical record resulted in increased high-quality communication between nurses and physicians around critical patient events.

Journal Article > Study

Impact of introducing an electronic physiological surveillance system on hospital mortality.

  • Classic

Schmidt PE, Meredith P, Prytherch DR, et al. BMJ Qual Saf. 2015;24:10-20.

Many patients show physiological signs of worsening for several hours prior to requiring more aggressive interventions and transfer to a higher level of care. Rapid response teams have been widely deployed to address this problem, but this approach is fundamentally reactive rather than proactive and has had mixed results so far. This time series study utilized an electronic physiological surveillance system—a real-time decision support system based on patients' vital signs—embedded within the electronic medical record to provide guidance for clinicians in determining patients at risk for deterioration and optimizing treatment intensity. Implementation of the electronic physiological surveillance system was associated with a statistically significant reduction in mortality for a broad range of diagnoses at both hospitals. The results of this study illustrate the potential of novel information technology approaches for prospectively identifying patients at risk for clinical harm.

Journal Article > Review

Reducing medication errors in critical care: a multimodal approach.

Kruer RM, Jarrell AS, Latif A. Clin Pharmacol. 2014;6:117-126.

In light of Institute of Medicine recommendations to redesign drug packaging and labeling to decrease medication errors, this review highlights challenges to medication safety in the intensive care unit associated with drug formulations and various routes of administration. The authors recommend a multimodal approach that combines system-level interventions, such as computerized provider order entry, simulation training, barcode medication administration, and incident reporting, to prevent adverse drug events.

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