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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.

Patient Safety Primers

Falls

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

Journal Article > Study

Innovative use of the electronic health record to support harm reduction efforts.

Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Pediatrics. 2017;139:e20153410.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for certain hospital-acquired conditions—an increasingly recognized source of preventable harm to patients. Researchers describe how they were able to reduce harm resulting from hospital-acquired conditions at their institution by more than 30% through improved use of electronic health record data and reporting tools.

Journal Article > Commentary

Estimating deaths due to medical error: the ongoing controversy and why it matters.

Shojania KG, Dixon-Woods M. BMJ Qual Saf. 2017;26:423-428.

A recent article asserted that medical error is the third leading cause of death in the United States. This perspective questions the accuracy of this estimate. The authors note that this estimate was generated by simply combining medical error rates from prior studies, without adhering to guidelines for quantitative synthesis or accounting statistically for the uncertainty associated with the extrapolation of these studies. There are also inherent limitations in the original data, which used trigger tools to identify adverse events. The studies from which the error rates were calculated could not clearly determine whether the adverse events detected actually contributed to the patient's death. Patients who are critically ill tend to have more adverse events because they experience more medical interventions. However, their deaths may be due to the underlying illness rather than the medical care they received. The authors argue that an inaccurately high estimate for medical error–related mortality draws attention away from other crucial patient harms, such as pressure ulcers and medication safety, both of which rarely contribute to mortality but are of high priority to patients.

Audiovisual

Making health care safer. Think sepsis. Time matters.

CDC Vital Signs. August 23, 2016.

Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

Journal Article > Study

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

Soban LM, Kim L, Yuan AH, Miltner RS. J Nurs Manag. 2016 Aug 4; [Epub ahead of print].

Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment to hospitals. In this study, researchers surveyed chief nursing officers across Veterans Health Administration acute care hospitals to better understand how organizational strategies are operationalized with regard to implementing pressure ulcer prevention programs. They found that such strategies were not operationalized in a uniform manner across the hospitals and that nurse leadership played a substantial role in influencing the implementation of pressure ulcer prevention initiatives.

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.

Journal Article > Commentary

Incorporating quality and safety values into a CLABSI simulation experience.

Liebrecht CM, Lieb MC. Nurs Forum. 2017;52:118-123.

Simulation has been promoted as a way to teach nurses about potential errors in their practice. This commentary describes the development of a program to help nurses recognize and correct weaknesses in their care processes that increase risk of central line–associated bloodstream infection.

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.

Book/Report

Eliminating Harm Checklists: Reduce All-Cause, Preventable Harm.

Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016.

Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.

Book/Report

Antibiotic Stewardship in Acute Care: A Practical Playbook.

National Quality Partners. Washington, DC: National Quality Forum; 2016.

Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.

Cases & Commentaries

Falling Through the Crack (in the Bedrails)

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

Patricia C. Dykes, PhD, RN; Wai Yin Leung, MS; and Vincent Vacca, RN, MSN; May 2016

Multiple alarms went off in an ICU room after an intern and resident performed paracentesis on an older patient. Nurses found the patient confused and trying to get out of bed. She had pulled out her nasogastric and endotracheal tubes, her leg was stuck in the bedrails, and she had a large cut on her foot.

Cases & Commentaries

Mismanagement of Delirium

  • Web M&M

Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS; May 2016

An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.

Journal Article > Commentary

Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.

Cerniglia-Lowensen J. J Radiol Nurs. 2015;34:4-7.

Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its value as a safety improvement strategy.

Journal Article > Study

Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance.

  • Classic

Chassin MR, Mayer C, Nether K. Jt Comm J Qual Patient Saf. 2015;41:4-12.

Although appropriate handwashing has been identified as an essential factor in preventing health care–associated infections, hand hygiene rates remain unacceptably low at many hospitals. This quality improvement project aimed to achieve adherence to hand hygiene practices at eight hospitals using change management methods drawn from human factors engineering. Each hospital investigated and identified specific causes of noncompliance with handwashing and developed specific interventions to address these barriers. These individualized efforts yielded a significant improvement in handwashing behavior. The authors argue that allowing each site to tailor the intervention to the specific causes of noncompliance led to the sustained improvements. This study suggests that local improvement may be a fruitful method to enhance the proven but incompletely implemented practice of hand hygiene. A recent AHRQ WebM&M interview and perspective discuss ways to enhance hand hygiene adherence.

Cases & Commentaries

A Stroke of Error

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

Kevin M. Barrett, MD, MSc; December 2014

An elderly man admitted for a presumed hypertensive emergency and undiagnosed neurologic symptoms became unresponsive and was noted to have new right hand weakness 2 days into his hospitalization. After a "Code Stroke" was called, a neurologist evaluated him and administered tPA 100 minutes after the acute event. A few hours later, the patient developed further symptoms, and an emergent head CT demonstrated post-tPA intracerebral hemorrhage.

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.

Newspaper/Magazine Article

Living with cancer: not talking about medical mistakes.

Gubar S. New York Times. October 30, 2014.

This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.

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.

Special or Theme Issue

From Science to Implementation: AHRQ's Program to Prevent HAIs—Results and Lessons.

Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.

This companion issue covers research findings by an AHRQ program to reduce health care–associated infections. Articles discuss antimicrobial stewardship programs, quality improvement assessment strategies, work-system factors that affect hospital-acquired infections, and prevention of central line–associated bloodstream infections as well as catheter-associated urinary tract infections.

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