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Search results for "Active Errors"

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Web Resource > Multi-use Website

Computer-based Provider Order Entry--CPOE.

ClinfoWiki: The Clinical Informatics Wiki.

This wiki article includes a definition of computer-based provider order entry and other information, such as system elements, implementation tips, and unintended consequences.

Journal Article > Study

Operational failures and interruptions in hospital nursing.

Tucker AL, Spear SJ. Health Serv Res. 2006;41:643-662.

This study discovered that nurses experienced more than eight work system failures during an 8-hour shift. Investigators combined primary observation with interview and survey methods to understand the role work system failures play on nurse effectiveness. The most frequent failures identified involved medications, orders, supplies, staffing, and equipment. In addition to operational failures that delayed productivity, a large number of reported work interruptions contributed to the study findings. The authors advocate for continued efforts to differentiate between tactics taken by bedside nurses to prevent error with tactics that result from the system (eg, interruptions), which often put patients at risk for error.

Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

This monthly selection of medication error reports discusses a mistake with chelation therapy agents due to similar acronym use, confusion of drugs similarly named in different countries, and inadequate information about changes to an existing drug.

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.

Newspaper/Magazine Article

Death due to pharmacy compounding error reinforces need for safety focus.

ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.

Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

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

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Journal Article > Study

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

Harris LM, Dreyer BP, Mendelsohn AL, et al. Acad Pediatr. 2017;17:403-410.

Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.

Journal Article > Commentary

Polypharmacy in the elderly—when good drugs lead to bad outcomes: a teachable moment.

Carroll C, Hassanin A. JAMA Intern Med. 2017 Apr 24; [Epub ahead of print].

Geriatric patients are particularly vulnerable to adverse drug events due to comorbidities, complicated care plans, and polypharmacy. This commentary describes how using STOPP criteria and performing indication mapping can help reduce polypharmacy and improve patient safety.

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

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.

Sharma M, Krishnamurthy M, Snyder R, Mauro J. Clin Pract. 2017;7:953.

Anticoagulants are considered high-risk medications due to their narrow therapeutic window and association with adverse drug events. This study suggests that integration of a clinical pharmacist into the inpatient team may help prevent anticoagulation dosing errors and resultant harm to patients.

Journal Article > Study

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study.

Gilmartin-Thomas JF, Smith F, Wolfe R, Jani Y. Int J Nurs Stud. 2017;72:15-23.

This prospective, direct-observation study examined medication administration accuracy of medications dispensed by nurses and caregivers in long-term care facilities. Investigators compared medication administration from original medication packaging to administration from multicompartment medication devices. The team observed nearly 2500 doses. When medications were dispensed from original packaging, the medication administration error rate was 9%. When multicompartment devices were used, the medication administration error rate was 3%. This difference persisted in settings where both original packaging and multicompartment medication devices were used. This study adds to the evidence about how literacy-friendly health systems can enhance medication safety.

Journal Article > Commentary

Elimination of emergency department medication errors due to estimated weights.

Greenwalt M, Griffen D, Wilkerson J. BMJ Qual Improv Rep. 2017;6:u214416.w5476.

Inaccurate assessments of patient weight can lead to medication dosing errors. This commentary describes how a single-center quality improvement project drew from errors in the emergency department associated with incorrect patient weight estimates and applied storytelling, Lean Six Sigma, and Fishbone diagram approaches to develop and test a method of entering weights that eliminated these errors during the 6-month intervention period.

Cases & Commentaries

Consequences of Medical Overuse

  • Spotlight Case
  • CME/CEU
  • Web M&M

Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

Cases & Commentaries

Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention

  • Web M&M

Scott D. Nelson, PharmD, MS; March 2017

Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.

Perspectives on Safety > Annual Perspective

Measuring and Responding to Deaths From Medical Errors

with commentary by Sumant Ranji, MD, 2016

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

Journal Article > Study

Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database.

Poudel DR, Acharya P, Ghimire S, Dhital R, Bharati R. Pharmacoepidemiol Drug Saf. 2017;26:635-641.

Analyzing data from the AHRQ Healthcare Cost and Utilization Project, this study found that hospitalizations related to adverse drug events increased from 2008 to 2011. These hospitalizations are common and costly, and they demonstrate higher odds of in-hospital death. These data underscore the urgent need to enhance medication safety.

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.

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