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Search results for "Active Errors"

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Cases & Commentaries

Delayed Recognition of a Positive Blood Culture

  • Web M&M

Sarah Doernberg, MD, MAS; July 2017

A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.

Cases & Commentaries

Pseudo-obstruction But a Real Perforation

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

Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS; July 2017

Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.

Journal Article > Study

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

Mody L, Greene MT, Meddings J, et al. JAMA Intern Med. 2017 May 19; [Epub ahead of print].

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

Journal Article > Commentary

Farewell to a cancer that never was.

Lyon J. JAMA. 2017;317:1824-1825.

Overdiagnosis can result in financial, psychological, and physical harm for patients. This commentary discusses the reclassification of a subtype of thyroid cancer as a nonmalignancy and the impact changing guidelines can have on patients.

Journal Article > Commentary

Polypharmacy in the elderly—when good drugs lead to bad outcomes: a teachable moment.

Carroll C, Hassanin A. JAMA Intern Med. 2017 Apr 24; [Epub ahead of print].

Geriatric patients are particularly vulnerable to adverse drug events due to comorbidities, complicated care plans, and polypharmacy. This commentary describes how using STOPP criteria and performing indication mapping can help reduce polypharmacy and improve patient safety.

Journal Article > Study

Innovative use of the electronic health record to support harm reduction efforts.

Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Pediatrics. 2017;139:e20153410.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.

Audiovisual

The War on Error: Common Diagnostic Errors.

Medscape. 2016–2017.

Improving diagnosis has recently been recognized as a primary focus for patient safety. This collection highlights particular clinical areas of concern such as neurology and infectious disease. The articles offer expert commentary and review strategies to avoid common reasoning errors.

Cases & Commentaries

Consequences of Medical Overuse

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

Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

Cases & Commentaries

Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention

  • Web M&M

Scott D. Nelson, PharmD, MS; March 2017

Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.

Journal Article > Commentary

Ethical dilemma in missed melanoma: what to tell the patient and other providers.

Vangipuram R, Horner ME, Menter A. J Am Acad Dermatol. 2017;76:365-367.

Despite the emphasis on open discussion of errors as a component of transparency, clinicians remain reluctant to disclose the errors of their peers to patients. This commentary discusses an incident involving a diagnosis of melanoma missed during the initial examination with a podiatrist that was later detected during a dermatology evaluation and describes how to manage such conversations between the providers as well as with the patient.

Journal Article > Study

Reevaluation of diagnosis in adults with physician-diagnosed asthma.

Aaron SD, Vandemheen KL, FitzGerald JM, et al; Canadian Respiratory Research Network. JAMA. 2017;317:269-279.

Misdiagnosis can contribute to overuse of unnecessary medication and treatments as well as a delay in appropriate treatment, placing patients at increased risk of harm. This prospective cohort study suggests that asthma may be frequently misdiagnosed in the community setting as a result of inadequate testing for airflow limitations. In 2% of the cases analyzed, a serious underlying cardiorespiratory condition was misdiagnosed as asthma.

Cases & Commentaries

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Cases & Commentaries

Hazards of Loading Doses

  • Web M&M

Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, PharmD; January 2017

An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level.

Journal Article > Study

Breast cancer screening in Denmark: a cohort study of tumor size and overdiagnosis.

  • Classic

Jørgensen KJ, Gøtzsche PC, Kalager M, Zahl P. Ann Intern Med. 2017;166:313-323.

The overuse of medical care is increasingly recognized as a patient safety issue. Overdiagnosis can result in unnecessary use of medical care, subjecting patients to greater risk of harm. For example, in the case of breast cancer, screening may detect lesions that are not clinically significant, leading to further testing and unnecessary procedures. This study examined the impact of mammography screening on a cohort of women in Denmark. Researchers found that screening was not associated with decreased incidence of advanced cancer but increased incidence of nonadvanced tumors and ductal carcinoma in situ; the rate of overdiagnosis was significant. An accompanying editorial discusses overdiagnosis in breast cancer.

Journal Article > Review

Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.

Nuckols TK, Keeler E, Morton SC, et al. JAMA Intern Med. 2016;176:1843-1854.

Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.

Cases & Commentaries

One Dose, Two Errors

  • Web M&M

Gregory A. Filice, MD; December 2016

An older woman experienced acute kidney injury after being prescribed a nephrotoxic medication (amphotericin) intended for the ICU patient in the next bed. Caring for both patients, the covering resident entered the medication order for the wrong patient despite a policy requiring infectious disease consultation to prescribe IV amphotericin.

Journal Article > Study

Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data.

Parsonage RK, Hiscock J, Law RJ, Neal RD. Br J Gen Pract. 2017;67:e49-e56.

Delays in cancer diagnosis constitute a common and serious patient safety problem. This study examined comments from newly diagnosed patients regarding diagnostic delays. Factors that influenced patients' perceptions of timely and accurate diagnosis included timeliness of screening, help-seeking behavior, and paying for private health services to avoid delays in the public health system.

Book/Report

Global Guidelines on the Prevention of Surgical Site Infection.

Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.

Cases & Commentaries

Unexpected Drawbacks of Electronic Order Sets

  • Web M&M

John D. McGreevey III, MD; November 2016

A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.

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.

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