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Approach to Improving Safety
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Search results for "Active Errors"

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Cases & Commentaries

Chest Tube Complications

  • Web M&M

Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD; June 2017

A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

Journal Article > Study

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

Mody L, Greene MT, Meddings J, et al. JAMA Intern Med. 2017 May 19; [Epub ahead of print].

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

Cases & Commentaries

Communication Error in a Closed ICU

  • Web M&M

Barbara Haas, MD, PhD, and Lesley Gotlib Conn, PhD; May 2017

Admitted to the ICU with septic shock, a man with a transplanted kidney developed hypotension and required new central venous access. Since providers anticipated using the patient's left internal jugular vein catheter for re-starting hemodialysis (making it unsuitable to use for resuscitation), the ICU team placed the central line in the right femoral vein. However, they failed to recognize that his transplanted kidney was on the right side, which meant that femoral catheter placement on that side was contraindicated.

Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Journal Article > Commentary

Retained lumbar catheter tip.

DeLancey JO, Barnard C, Bilimoria KY. JAMA. 2017;317:1269-1270.

Retained surgical items are considered a sentinel event. Discussing an incident involving the unintended retention of a catheter tip in a patient, this commentary explains why adequate supervision, communication, and clearly articulated responsibilities are important to enhance patient safety.

Journal Article > Commentary

Management of a patient with a latex allergy.

Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.

This case analysis discusses the use of a latex catheter in a patient with a known latex allergy and presents how root cause analysis identified factors that contributed to the error. Recommended corrective actions included educating staff about latex allergies and using a checklist to address communication, documentation, and process weaknesses.

Cases & Commentaries

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Newspaper/Magazine Article

Accidental IV infusion of heparinized irrigation in the OR.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.

Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.

Journal Article > Review

Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.

Nuckols TK, Keeler E, Morton SC, et al. JAMA Intern Med. 2016;176:1843-1854.

Central line–associated bloodstream infections (CLABSIs) represent a key source of preventable harm to patients, and they are associated with increased morbidity and mortality. Prior research has shown that interventions to reduce CLABSIs result in significant cost savings to the health system but may decrease profit margins for hospitals. This systematic review examined the economic value of quality improvement efforts to reduce CLABSIs and catheter-related bloodstream infections (CRBSIs). Based on results from 15 studies, investigators concluded that hospital spending on CLABSI and CRBSI prevention efforts is worthwhile, leading to significant hospital savings as well as marked reductions in bloodstream infections. A PSNet perspective discussed the role of infection prevention in patient safety.

Journal Article > Commentary

Performing the wrong procedure.

Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.

Describing an incorrect procedure incident which involved placement of a dialysis catheter instead of a central line, this commentary outlines the root causes of the event and how it could have been prevented. A related editorial introduces Performance Improvement, a series of case-based articles intended to support frontline performance improvement efforts.

Journal Article > Study

Incidence of speech recognition errors in the emergency department.

Goss FR, Zhou L, Weiner SG. Int J Med Inform. 2016;93:70-73.

The adoption of new technology in health care often produces unintended consequences, which can be mitigated by applying human factors engineering principles to user interface design. Due to efficiency gains, the use of speech recognition technology among physicians has grown in recent years. Investigators analyzed notes dictated by emergency medicine physicians and found that 71% of the notes contained errors. Given that 15% of the errors were considered critical, the authors suggest speech recognition technology may create miscommunication that could adversely affect patient care.

Journal Article > Review

A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes.

Manojlovich M, Lee S, Lauseng D. J Patient Saf. 2016;12:173-179.

Interventions intended to enhance patient safety may have unanticipated consequences. This systematic review found that unintended consequences of patient safety interventions, positive and negative, are common. Researchers recommend that all patient safety interventions should be monitored for these unexpected outcomes.

Cases & Commentaries

Picking Up the Cause of the Stroke

  • Web M&M

Vineet Chopra, MD, MSc; February 2016

Hospitalized with poorly controlled diabetes, a man had a peripherally inserted central catheter (PICC) placed for intravenous pain medications, intravenous fluids, and parenteral nutrition. The next day, the patient complained of headache, unilateral vision loss, and left-sided tingling and numbness. Misplacement of the PICC in a left-sided superior vena cava had led to embolic strokes.

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.

Legislation/Regulation

Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff.

Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food and Drug Administration. July 9, 2015;80:39440-39441.

Heparin is a high-alert anticoagulant that has been associated with patient harm due to issues with administration and contamination. This draft guidance seeks to engage insights from the field to help improve labeling practices. The deadline for officially submitting comments was October 7, 2015.

Cases & Commentaries

Unseen Perils of Urinary Catheters

  • Web M&M

Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RN; June 2015

A hospitalized older man with a complicated medical history had not voided in several hours. The patient voided just prior to catheter insertion, which produced no urine, and the nurse assumed that meant the patient's bladder was empty. Two hours later the patient complained of discomfort and a blood clot was found in his tubing. Continuous bladder irrigation was ordered, but the pain became worse. Urgent consultation by urology revealed that the urinary catheter was not in the bladder.

Cases & Commentaries

Departure From Central Line Ritual

  • Web M&M

Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD; May 2015

A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.

Journal Article > Commentary

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2015;122:495-520.

This practice advisory summarizes the literature and expert opinion to advise practitioners on the dangers of administering anesthesia to patients receiving magnetic resonance imaging, or MRIs.

Cases & Commentaries

Medical Devices in the "Wild"

  • Web M&M

Ayse P. Gurses, PhD, and Peter Doyle, PhD; December 2014

An elderly man was being prepared for discharge after being hospitalized for an exacerbation of congestive heart failure. His nurse failed to notice that the tubing of the patient's sequential compression devices (in place to prevent DVT) was caught on the bed wheel and had unlocked the bed when she raised it. When the patient attempted to get up later, the bed rolled out from under him and he fell, breaking his hip. One week after surgery, the patient experienced a cardiac arrest from a massive pulmonary embolism and died.

Journal Article > Study

Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.

Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.

Catheter-associated infections are common, and largely preventable, adverse events. Though incidence of these events has declined due to intensive safety efforts, one factor contributing to intravenous catheter infections is the failure to remove unnecessary central venous catheters (CVCs). This study sought to determine whether inpatient physicians know which of their patients have CVCs in place by comparing physician response to direct observation of each patient. Physicians were unaware of CVCs in about 20% of the cases examined. Trainee physicians were more likely to be aware of a CVC than teaching attending physicians or hospitalists, and critical care physicians were more likely to know about a CVC than general medicine physicians. These findings suggest that interventions to reduce CVC-associated infections should address clinician awareness of CVCs. An AHRQ WebM&M commentary discusses best practices for removing CVCs.

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