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Cases & Commentaries
Situational Awareness and Patient Safety
- Web M&M
Jeanne M. Farnan, MD, MHPE; April 2016
A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.
Journal Article > Review
Hardwiring patient blood management: harnessing information technology to optimize transfusion practice.
Dunbar NM, Szczepiorkowski ZM. Curr Opin Hematol. 2014;21:515-520.
Mistakes during blood transfusion can contribute to patient harm. This review discusses the use of health information technology, such as computerized provider order entry and clinical decision support systems, in transfusion medicine to enhance reliability of ordering practices and enable monitoring of adherence.
Journal Article > Study
Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.
Desai RJ, Williams CE, Greene SB, Pierson S, Hansen RA. J Healthc Risk Manag. 2013;33:33-43.
Patients in nursing homes are generally elderly, chronically ill, and take multiple medications, which places them at higher risk for medication errors. The state of North Carolina maintains a mandatory medication error reporting system for all nursing homes. This study analyzed data from this system to characterize errors due to anticoagulant drugs (which are considered high-risk medications). Errors were found to be common and harmful, often due to inadequate monitoring to ensure appropriate drug dosing. The authors recommend several potential solutions, but any interventions will likely also have to address the fact that safety culture in nursing homes is generally poor. An AHRQ WebM&M commentary discusses a preventable error due to inadequate monitoring of the anticoagulant warfarin at a nursing home, and an AHRQ WebM&M perspective explores the difficult problem of ensuring medication safety in nursing facilities.
Journal Article > Review
Practices to prevent venous thromboembolism: a brief review.
Lau BD, Haut ER. BMJ Qual Saf. 2014;23:187-195.
This review examined the efficacy of different strategies for preventing venous blood clots during hospitalization. The most successful interventions combined education with computerized tools.
Cases & Commentaries
Transfusion Overload
- Spotlight Case
- Web M&M
Manish S. Patel, MD, and Jeffrey L. Carson, MD; November 2012
At a skilled nursing facility, an elderly woman with myelodysplastic syndrome was found to be mildly anemic, and her oncologist arranged for her to be sent to the hospital and transfused with 2 units of blood. Less than 1 hour after the second unit of blood finished transfusing, the patient rapidly worsened and had a respiratory arrest.
Journal Article > Study
Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma.
Haut ER, Lau BD, Kraenzlin FS, et al. Arch Surg. 2012;147:901-907.
A mandatory computerized clinical decision support tool improved deep vein thrombosis (DVT) prophylaxis rates and decreased preventable DVTs in trauma patients.
Newspaper/Magazine Article
Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.
Boodman SG. Washington Post. June 13, 2011:E1.
This newspaper article reveals how biases and lack of trust in the patient/family perspective may contribute to diagnostic error.
Journal Article > Study
Medication errors in the homes of children with chronic conditions.
Walsh KE, Mazor KM, Stille CJ, et al. Arch Dis Child. 2011;96:581-586.
Medication errors can be difficult to detect in ambulatory care, as patients or caregivers administer medications instead of health care providers. This descriptive study used home visits to children with chronic diseases to identify medication errors committed by parents, and found a remarkably high incidence of errors, particularly when parents did not use aids or support tools to help with medication administration. Although many errors were attributable to suboptimal provider–patient communication, physicians were unaware of errors in 80% of cases. An AHRQ WebM&M commentary discusses the effects of parental misunderstanding of medication instructions for their child.
Newspaper/Magazine Article
MGH faces suit over drug error that killed woman.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Journal Article > Study
Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.
Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.
Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.
Journal Article > Study
Error in body weight estimation leads to inadequate parenteral anticoagulation.
Dos Reis Macedo LG, de Oliveira L, Pintão MC, Garcia AA, Pazin-Filho A. Am J Emerg Med. 2011;29:613-617.
Inadequate dosing of anticoagulant medications was common in the emergency department due to inaccurate estimation of body weight.
Journal Article > Commentary
Dealing honestly with an honest mistake.
Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.
This case report describes a near miss involving a potential heparin overdose and discusses what physicians should tell patients in similar circumstances.
Journal Article > Study
Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.
McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.
This article describes the process used to detect mismatched umbilical cord blood prior to transplantation. Failure to detect the mismatches would have led to devastating clinical consequences.
Journal Article > Commentary
Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.
Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.
This article discusses hospital compliance with National Patient Safety Goals regarding medication safety and describes strategies to improve anticoagulant administration safety.
Journal Article > Commentary
New technology for transfusion safety.
Dzik WH. Br J Haematol. 2007;136:181-90.
The author discusses three transfusion case studies that highlight three areas where errors are most common and technologies that can be used to prevent errors in these areas.