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Approach to Improving Safety
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Search results for "Active Errors"

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Special or Theme Issue

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.

Journal Article > Study

Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit.

Solanki R, Mondal N, Mahalakshmy T, Bhat V. Arch Dis Child. 2017 May 3; [Epub ahead of print].

Pediatric patients are at high risk for medication errors. Researchers conducted a cross-sectional study on 166 infants younger than 3 months who were discharged from the hospital. They found a high frequency of medication errors by caregivers. In keeping with prior research, dose administration errors were the most common type of error.

Journal Article > Commentary

An innovative collaborative model of care for undiagnosed complex medical conditions.

Nageswaran S, Donoghue N, Mitchell A, Givner LB. Pediatrics. 2017;139:e20163373.

Lack of collaboration among the clinical team can contribute to diagnostic problems. This commentary describes a collaborative model of care developed to enhance interdisciplinary teamwork across health care settings as a strategy to augment diagnosis for children with undiagnosed complex medical conditions.

Journal Article > Study

Evaluating serial strategies for preventing wrong-patient orders in the NICU.

Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139:e20162863.

Wrong-patient errors are a well-established risk in the health care setting. Research has shown that providers, often multitasking, may enter notes or medication orders for the wrong patient. A prior study touted point-of-care photographs as a helpful intervention for identifying and preventing wrong-patient errors in a cardiothoracic intensive care unit. However, less is known about wrong-patient errors in the neonatal intensive care unit (NICU) population and ways to prevent them. Researchers analyzed more than 850,000 NICU orders and more than 3.5 million non-NICU orders in pediatric patients over a 7-year period. At baseline, they found that wrong-patient orders occurred more frequently in the NICU population with an odds ratio of 1.56. Interventions included requiring reentry of patient identifiers prior to order entry as well as a new naming system for newborns. Implementation of both led to a 61.1% reduction in wrong-patient errors in the NICU population from baseline. A previous WebM&M commentary highlights a case of wrong-patient identification.

Journal Article > Study

Prescription errors related to the use of computerized provider order-entry system for pediatric patients.

Alhanout K, Bun SS, Retornaz K, Chiche L, Colombini N. Int J Med Inform. 2017;103:15-19.

Computerized provider order entry has been shown to decrease adverse drug events, but it can also introduce new medication errors. This retrospective study examined medication ordering errors intercepted by pharmacists for pediatric patients. As with prior studies in pediatrics, this investigation uncovered dosing errors associated with weight-based dosing, including calculation errors and missing weight information. The most common medication associated with errors was acetaminophen, which can cause severe harm if incorrectly dosed. The authors call for improving electronic health record prescribing interfaces, better user training, and enhancing communication among providers to prevent medication errors.

Journal Article > Study

Overdose risk in young children of women prescribed opioids.

Finkelstein Y, Macdonald EM, Gonzalez A, Sivilotti MLA, Mamdani MM, Juurlink DN; Canadian Drug Safety And Effectiveness Research Network (CDSERN). Pediatrics. 2017;139:e20162887.

Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.

Journal Article > Review

Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors.

Dreisinger N, Zapolsky N. Pediatr Emerg Care. 2017;33:128-131.

Emergency departments (ED) are complex environments that are prone to medical error. This review discusses elements of ED care that detract from patient safety and highlights the importance of reporting and discussing errors when they take place to develop prevention strategies. The authors also explore the evidence on transparency in the ED when an error occurs and how to make an appropriate apology.

Journal Article > Study

Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis.

Rees P, Edwards A, Powell C, et al. PLoS Med. 2017;14:e1002217.

Since the inception of the patient safety movement, most research has focused on the inpatient setting. Although the focus on ambulatory safety has grown in recent years, little is known about adverse events in outpatient pediatric care. In this mixed methods study, researchers analyzed incident reports involving sick pediatric primary care patients from the England and Wales' National Reporting and Learning System over a 9-year period. Using descriptive and thematic analysis, researchers sought to identify the most common and serious event types, reasons these events occurred, and opportunities for improving safety. They found that about one third of 2191 safety incidents represented cases of severe harm. Based on their analysis, the authors conclude that efforts should focus on building safer systems for medication dispensing in community pharmacies, enhancing the triage process for sick children, and improving communication between providers and parents. An accompanying editorial discusses the value of incident reports with regard to improving care for pediatric primary care patients.

Journal Article > Commentary

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

Journal Article > Study

Assessing frequency and risk of weight entry errors in pediatrics.

Hagedorn PA, Kirkendall ES, Kouril M, et al. JAMA Pediatr. 2017;171:392-393

Weight-based medication dosing can lead to medication errors in pediatric patients. Investigators used a trigger tool to detect weight-entry errors in the electronic health record. They found that dosing errors are rare and are most likely to occur in urgent and emergent settings. These findings suggest that a weight-entry trigger tool can identify pediatric patients at risk for dosing errors.

Journal Article > Study

Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study.

Carlotti AP, Bachette LG, Carmona F, Manso PH, Vicente WV, Ramalho FS. Am J Clin Pathol. 2016;146:701-708.

This autopsy study demonstrated significant discrepancies between clinical and postmortem diagnoses among children who died in the intensive care unit. These results demonstrate the importance of autopsy as an educational tool for clinical teams to improve patient outcomes.

Journal Article > Commentary

Inappropriate opioid dosing and prescribing for children: an unintended consequence of the clinical pain score?

Voepel-Lewis T, Malviya S, Tait AR. JAMA Pediatr. 2017;171:5-6.

Opioid prescribing is gaining attention as a high-risk activity in both general and pediatric care. This commentary explains how well-intentioned efforts to manage pain in children might have unintentionally contributed to the opioid epidemic. The authors suggest that policy approaches may help address the problem at the system level.

Journal Article > Commentary

Handoffs: transitions of care for children in the emergency department.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Emergency Medicine Committee; Emergency Nurses Association Pediatric Committee. Pediatrics. 2016;138:e20162680.

Improvement efforts have focused on care transitions, which are known to be vulnerable to communication failures. This guideline provides recommendations for ensuring handoffs are performed in pediatric emergency care and suggests adherence to standard communication methods, coupled with effective training on the use of those tools, can improve the safety of transitions.

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.

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.

Journal Article > Study

PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique.

Barry E, O'Brien K, Moriarty F, et al; PIPc Project Steering group. BMJ Open. 2016;6:e012079.

Although certain medication classes pose increased risks to children, well-defined criteria for potentially inappropriate prescribing for pediatric patients have not been established. This study described an iterative consensus-building process which identified 12 indicators of potentially inappropriate medications for children. Future studies will test the validity of these indicators.

Journal Article > Commentary

Medication errors in outpatient pediatrics.

Berrier K. MCN Am J Matern Child Nurs. 2016;41:280-286.

Medication errors occur in various care environments, and they are common in the outpatient setting. This commentary describes factors that contribute to incorrect medication administration by parents, such as misunderstanding of instructions due to insufficient health literacy. The author proposes several tactics to promote safe medication practices by parents which include picture-based instructions and standardized dosing instruments.

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 > Commentary

​Pediatric chest radiographs: common and less common errors.

Menashe SJ, Iyer RS, Parisi MT, Otto RK, Stanescu AL. AJR Am J Roentgenol. 2016 Aug 4; [Epub ahead of print].

This commentary reviews nine cases involving interpretation errors associated with chest radiographs of children to illustrate common mistakes that can occur in pediatric imaging. Each case concludes with a clinical teaching point for practice improvement.

Book/Report

Learning From Mistakes.

London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.

The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.

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