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Search results for "Active Errors"

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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

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

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 > 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.

Journal Article > Study

Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.

Elmore JG, Tosteson AN, Pepe MS, et al. BMJ. 2016;353:i3069.

This study found that eliciting second opinions in pathology improved the accuracy of breast histopathology specimens. This work provides further evidence that diagnostic accuracy can be enhanced with second opinions. The authors suggest that implementing multiple clinician review may augment the diagnostic process.

Cases & Commentaries

The Fluidity of Diagnostic "Wet Reads"

  • Web M&M

Cindy S. Lee, MD, and Christopher P. Hess, MD, PhD; May 2016

An older man with a history of heavy smoking and chest pain underwent a chest CT in the emergency department that showed no evidence of an aortic dissection on the preliminary read. Although the patient followed up soon thereafter with a new primary care physician, it was not discovered until several months later that a suspicious lung nodule had been spotted on the initial CT.

Journal Article > Commentary

Two fatal cases of accidental intrathecal vincristine administration: learning from death events.

Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Chemotherapy. 2015;61:108-110.

Incorrectly administered vincristine can lead to serious adverse consequences. Discussing two incidents involving accidental intrathecal vincristine administration, this commentary describes how the health care organization implemented changes (including using different bags for drugs and label colors for syringes) following the first event and made further revisions when the second incident occurred 7 years later (such as ensuring drugs are delivered during different times and in certain settings).

Newspaper/Magazine Article

Selection of incorrect medication pump leads to chemotherapy overdose.

ISMP Canada. August 26, 2015;15:1-4.

Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. In response to an incident involving a chemotherapy administration error as a result of utilizing the incorrect infusion pump, this newsletter article discusses the development of a point-of-care checklist to assist in use of infusion pumps to improve safety.

Journal Article > Study

The impact of a computerized physician order entry system on medical errors with antineoplastic drugs 5 years after its implementation.

Sanchez Cuervo M, Rojo Sanchis A, Pueyo Lopez C, Gomez de Salazar Lopez de Silanes E, Gramage Caro T, Bermejo Vicedo T. J Clin Pharm Ther. 2015 Jul 14; [Epub ahead of print].

Computerized provider order entry (CPOE) has been shown to decrease some adverse drug events (ADEs), but it has also introduced medication errors across multiple settings. This study examined the incidence of ADEs in an inpatient hematology–oncology setting in three timeframes: before CPOE, immediately following implementation, and 5 years later. Although researchers found a significant reduction in ADEs, some errors persisted. These results argue for continued development of decision support to enhance prescribing, particularly in high-risk environments such as inpatient cancer treatment. A past AHRQ WebM&M interview discussed how technology can augment medication safety.

Newspaper/Magazine Article

Accidental overdoses involving fluorouracil infusions.

ISMP Medication Safety Alert! Acute Care Edition. June 18, 2015;20:1:5.

Describing three accidental overdoses of the antineoplastic drug fluorouracil which involved pump failure, labeling confusion, and omission of a double-check, this newsletter article outlines recommendations to prevent such errors.

Web Resource > Multi-use Website

Radiation Oncology Incident Learning System.

American Society for Radiation Oncology and American Association of Physicists in Medicine.

Reporting of near misses and adverse events can provide a foundation for learning from error. This Web site supports an online portal facilitating incident reporting to enable data and experience analysis that will be used to inform development of guidelines and educational programs to promote safe practice in radiation oncology.

Journal Article > Review

Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods.

Carter JL, Coletti RJ, Harris RP. BMJ. 2015;350:g7773.

Seeking to identify the best strategies for accurately quantifying and monitoring overdiagnosis over time, this systematic review examined studies that measured overdiagnosis rates for nine common cancers. The authors concluded that ecological and cohort studies led by unbiased researchers show the most promise for monitoring overdiagnosis in cancer screening programs.

Journal Article > Commentary

Rethinking diagnostic delay in cancer: how difficult is the diagnosis?

Lyratzopoulos G, Wardle J, Rubin G. BMJ. 2014;349:g7400.

Past studies have found that delays in cancer diagnosis are common and harmful. Suggesting that such delays are not always due to error, this commentary reviews how diagnostic difficulty can lead to multiple consultations and hinder timely diagnosis of cancer in primary care.

Newspaper/Magazine Article

Hamilton father misdiagnosed with lung cancer demands answers.

Carville O. The Star. November 14, 2014.

This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and touches on the psychological impact of diagnostic error on the patient and his family. The potential causes of the mistake include laboratory sample confusion and misinterpretation of biopsy results.

Journal Article > Study

Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.

Greenall J, Shastay A, Vaida AJ, et al. J Oncol Pharm Pract. 2015;21:26-35.

In 2012, more than 350 organizations from 13 countries participated in the initial Institute for Safe Medication Practices self-assessment for oncology. This study describes results from this baseline survey, which revealed key opportunities for improvements in the safe delivery of chemotherapy. For example, many institutions have still not followed best practices for the administration of vincristine. In addition, less than half of respondents had fully implemented safety processes for oral chemotherapy orders. A prior AHRQ WebM&M commentary describes a patient who inadvertently received the wrong chemotherapy regimen and explores the high risks associated with inpatient chemotherapy.

Journal Article > Review

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use.

Kukreti V, Cosby R, Cheung A, Lankshear S; ST Computerized Prescriber Order Entry Guideline Development Group. Curr Oncol. 2014;21:e604-e612.

Medication error rates are extremely high among patients receiving outpatient chemotherapy. This systematic review found a paucity of studies on the effectiveness of computerized provider order entry (CPOE) in improving the safety of chemotherapy, but concluded that the limited evidence supports wider use of CPOE in this setting.

Newspaper/Magazine Article

With oral chemotherapy, we simply must do better!

ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.

To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.

Journal Article > Study

Trade-offs between voice and silence: a qualitative exploration of oncology staff's decisions to speak up about safety concerns.

Schwappach DLB, Gehring K. BMC Health Serv Res. 2014;14:303.

Although doctors and nurses in an oncology unit all agreed on the importance of speaking up in unsafe situations, they described various barriers to actually doing so, including the potential to damage relationships and concern about the accuracy of their own assessment of the situation.

Journal Article > Study

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

Prakash V, Koczmara C, Savage P, et al. BMJ Qual Saf. 2014;23:884-892.

This study used high-fidelity simulation to evaluate the impact of several interventions on preventing medication administration errors by chemotherapy nurses. Interventions with a basis in human factors engineering principles appeared to be highly effective at reducing errors related to interruptions.

Journal Article > Study

Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids.

Franklin BD, Panesar SS, Vincent C, Donaldson LJ. BMJ Qual Saf. 2014;23:765-772.

Although there have been no reported accidental spinal injection of a vinca alkaloid in the United Kingdom since 2001, this study looked at upstream safety issues that could cause this fatal complication. The method used in this study provides a model for evaluating the resilience of safety practices, even in the absence of actual harmful events.

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