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Approach to Improving Safety
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Search results for "Active Errors"

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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 > 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

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

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

Hughes KM, Goswami ES, Morris JL. J Pediatr Pharmacol Ther. 2015;20:453-461.

Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.

Journal Article > Study

Use of temporary names for newborns and associated risks.

  • Classic

Adelman J, Aschner J, Schechter C, et al. Pediatrics. 2015;136:327-333.

Wrong-patient errors are considered to be never events. Newborns are assigned temporary names if they don't have a name immediately after birth, and this may increase the rates of wrong-patient errors. The need for first and last names in electronic health records has led to a generic first name convention of "Babygirl" or "Babyboy," which is in use in more than 80% of neonatal intensive care units in the United States. This pre-post study found that implementing specific first names that incorporated the mother's name reduced the incidence of wrong-patient errors by 36% compared to the generic naming. These errors are rare even at baseline, but given the ease of changing the naming convention, this is a pragmatic approach to improving the safety of computerized provider order entry for hospitalized newborns.

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

Parents' perspective on safety in neonatal intensive care: a mixed-methods study.

Lyndon A, Jacobson CH, Fagan KM, Wisner K, Franck LS. BMJ Qual Saf. 2014; 23:902-909.

This interview, observation, and survey study found that parents of infants in neonatal intensive care units identified three core aspects of safety: physical safety relating to immediate treatment, the effect of care on future development, and emotional safety for infants and family, such as having confidence in caregivers. These results argue for enhancing patient and family engagement in safety in this setting.

Cases & Commentaries

Late Anemia Following Rh Disease in a Newborn

  • Web M&M

Thomas B. Newman, MD, MPH, and M. Jeffrey Maisels, MB, BCh, DSc; March 2014

Following delivery and successful phototherapy for hyperbilirubinemia, an infant developed anemia over the next few weeks. Found to have Rh hemolytic disease, the infant was admitted to the hospital for blood transfusion and close monitoring.

Journal Article > Commentary

Developing a quality and safety curriculum for fellows: lessons learned from a neonatology fellowship program.

Gupta M, Ringer S, Tess A, Hansen A, Zupancic J. Acad Pediatr. 2014;14:47-53.

This commentary describes the development and implementation of a quality and safety curriculum.

Newspaper/Magazine Article

Baby's death spotlights safety risks linked to computerized systems.

Graham J, Dizikes C. Chicago Tribune. June 27, 2011.

This newspaper article reports on an order entry error that resulted in a 60-fold overdose and raised concerns about the safety of electronic medication data systems.

Newspaper/Magazine Article

Another tragic parenteral nutrition compounding error.

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

This article analyzes a fatal error involving parenteral nutrition and makes recommendations to prevent such incidents.

Journal Article > Study

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

This research letter reports on studies that explored the potential dosing errors associated with preparation of intravenous solutions for pediatric patients.

Newspaper/Magazine Article

Safety shortcomings spotted in Sunrise catheter case.

Harasim P. Las Vegas Review-Journal. November 21, 2010;News:1B.

This article discusses how the organizational system of one hospital delayed an investigation into catheter line malfunctions.

Newspaper/Magazine Article

Dennis Quaid's Quest.

Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.

This article highlights how a medication error inspired Dennis Quaid to promote patient safety and chronicles his efforts to reduce harm in health care.

Cases & Commentaries

Fatal Error in Neonate: Does "Just Culture" Provide an Answer?

  • Spotlight Case
  • Web M&M

Sidney W.A. Dekker, PhD; June 2010

An infant born prematurely received a lethal overdose of lipid emulsion. The nurse involved in the incident was fired, and no further investigation occurred.

Journal Article > Study

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

De Giorgi I, Fonzo-Christe C, Cingria L, et al. Int J Qual Health Care. 2010;22:170-178.

This study used failure modes and effects analysis to identify the major hazards associated with intravenous medication administration and cost-effective approaches for improving safety.

Audiovisual

Nebraska Medical Center investigates staff after girl's death.

Luby R. KETV. Omaha, NE. March 31, 2010.

This news piece focuses on a heparin overdose that resulted in the death of a toddler.

Journal Article > Study

Physician order entry or nurse order entry? Comparison of two implementation strategies for a computerized order entry system aimed at reducing dosing medication errors.

Kazemi A, Fors UG, Tofighi S, Tessma M, Ellenius J. J Med Internet Res. 2010;12:e5.

Computerized provider order entry is usually considered to be synonymous with computerized physician order entry. However, in this Iranian study, having nurses enter medication orders (which physicians subsequently countersigned) resulted in significantly fewer medication errors.

Journal Article > Study

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

This study advocates for computerized assistance to reduce errors and the time required for drug administration calculations. The authors also highlight the importance of optimizing drug labels to ensure safety.

Journal Article > Study

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

This study reports on a quality improvement effort to eliminate errors due to look-alike, sound-alike medications.

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