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Search results for "Active Errors"

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Journal Article > Study

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

Jones A, Johnstone MJ. Aust Crit Care. 2017;30:219-223.

This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.

Journal Article > Study

Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.

Koch SH, Weir C, Haar M, et al. J Am Med Inform Assoc. 2012;19:583-590.

The commonly used expression "missing the forest for the trees" is a shorthand summary of the concept of situational awareness—the degree to which a clinician's perception matches reality. Situational awareness requires that clinicians can perceive the information they need, comprehend the importance of this information, and forecast the implications of this information (i.e., adverse consequences that might happen). Nurses' role in patient safety is largely dependent on maintaining situational awareness, and this study used direct observation of intensive care unit (ICU) nurses in three hospitals to assess the degree to which monitoring devices and other information displays supported each phase of situational awareness. The authors found that the design of bedside information displays often impaired nurses' ability to gather critical patient data, particularly around medications, resulting in the potential to harm situational awareness. The authors make recommendations, based on human factors engineering principles, to improve the quality of information displays in the ICU.

Journal Article > Study

Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care nurses.

Maiden J, Georges JM, Connelly CD. Dimens Crit Care Nurs. 2011;30:339-345.

This survey of intensive care unit nurses revealed many barriers to reporting medication errors, and nurses reporting higher levels of burnout had more strongly negative opinions of the utility of error reporting.

Newspaper/Magazine Article

Too many abandon the "second victims" of medical errors.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.

This piece discusses second victims and describes how five factors can help clinicians involved in adverse events.

Cases & Commentaries

Are We Pushing Graduate Nurses Too Fast?

  • Web M&M

Nancy Spector, PhD, RN ; March 2011

While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.

Journal Article > Commentary

Preventing sentinel events caused by family members.

Wall Y, Kautz DD. Dimens Crit Care Nurs. 2011;30:25-27.

This commentary discusses errors in patient care caused by family members and suggests that involving patients and families in patient awareness programs can help prevent such incidents.

Journal Article > Study

Medical errors recovered by critical care nurses.

Dykes PC, Rothschild JM, Hurley AC. J Nurs Adm. 2010;40:241-246.

This survey of critical care nurses revealed that nurses witness and are involved in preventing a wide variety of errors, nearly one-fourth of which were considered potentially lethal.

Cases & Commentaries

Medication Reconciliation Pitfalls

  • Web M&M

Robert J. Weber, PharmD, MS; February 2010

An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.

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

Safety as a criterion for quality: The Critical Nursing Situation Index in paediatric critical care, an observational study.

de Neef M, Bos AP, Tol D. Intensive Crit Care Nurs. 2009;25:341-347.

This study describes the Critical Nursing Situation Index (CNSI), an observational tool that identifies deviations from safe practice, and focuses on potential nursing errors before they occur.

Journal Article > Commentary

Patient safety and collaboration of the intensive care unit team.

Despins LA. Crit Care Nurse. April 2009;29:85-91.

This article describes how patient safety and team coordination in the ICU are connected. The author recommends team training as an approach to enhance collaboration.

Journal Article > Study

Competence and certification of registered nurses and safety of patients in intensive care units.

Kendall-Gallagher D, Blegen MA. Am J Crit Care. 2009;18:106-113.

Intensive care units with a higher proportion of certified registered nurses had lower rates of certain patient safety outcomes, including incidence of falls. Greater nursing experience also was correlated with lower rates of medication errors.

Cases & Commentaries

Double Dosing, by the Rules

  • Web M&M

Hedy Cohen, RN, BSN, MS; February-March 2009

New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.

Cases & Commentaries

Where's the Feeding Tube?

  • Web M&M

Norma A. Metheny, RN, PhD; Kathleen L. Meert, MD; September 2008

A boy was receiving enteral feedings while recovering from a traumatic brain injury. The nasojejunal tube migrated to the gastric area, and the patient developed pneumonia, likely due to aspiration.

Journal Article > Study

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

Berkenstadt H, Haviv Y, Tuval A, et al. Chest. 2008;134:158-162.

Simulation training is being widely implemented in health care, in settings ranging from the emergency department to the operating room. Acting in response to an incident of preventable hypoglycemia, this Israeli hospital conducted a simulation training exercise focusing on teamwork training for nurses, with the goal of improving patient handoffs. The intervention resulted in improvement in nurses' communication of critical information during handoffs.

Journal Article > Commentary

Unreported errors in the intensive care unit: a case study of the way we work.

Henneman EA. Crit Care Nurse. 2007;27:27-34.

This commentary uses two medication error reporting failures to provide insight into the social and cultural factors that influence incident reporting.

Cases & Commentaries

On the Other Hand

  • Web M&M

Elizabeth A. Henneman, RN, PhD; May 2007

A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.

Cases & Commentaries

Thin Air

  • Spotlight Case
  • Web M&M

David M. Gaba, MD ; October 2004

A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air.

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