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Search results for "Active Errors"

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Journal Article > Study

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

Armstrong GE, Dietrich M, Norman L, Barnsteiner J, Mion L. J Nurs Care Qual. 2017;32:226-233.

Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.

Journal Article > Commentary

Recommended responsibilities for management of MR safety.

Calamante F, Ittermann B, Kanal E, Norris D; Inter-Society Working Group on MR Safety. J Magn Reson Imaging. 2016;44:1067-1106.

Magnetic resonance safety events can lead to serious patient harm. This commentary provides recommendations from expert consensus to help organizations design and implement a range of magnetic resonance imaging services. The authors also define three levels of management responsibilities required to support those recommendations in a various settings.

Cases & Commentaries

The Case of Mistaken Intubation

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

Maria J. Silveira, MD, MA, MPH; June 2016

An older man with multiple medical conditions was found hypoxic, hypotensive, and tachycardic. He was taken to the hospital. Providers there were unable to determine the patient's wishes for life-sustaining care, and, unaware that he had previously completed a DNR/DNI order, they placed him on a mechanical ventilator.

Clinical Guideline

Society of Interventional Radiology IR Pre-Procedure Patient Safety Checklist by the Safety and Health Committee.

Rafiei P, Walser EM, Duncan JR, et al; Society of Interventional Radiology Health and Safety Committee. J Vasc Interv Radiol. 2016;27:695-699.

Most research has focused on developing and implementing checklists in surgical settings. This guideline recommends a set of pre-procedure checklist items and offers rationales for each to help hospitals develop a checklist for use in interventional radiology.

Journal Article > Commentary

Disclosure of medical errors involving gametes and embryos.

Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.

This publication advocates for open disclosure of errors in reproductive medicine.

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.

Web Resource > Multi-use Website

Radiation Oncology Incident Learning System.

American Society for Radiation Oncology and American Association of Physicists in Medicine.

Reporting of near misses and adverse events can provide a foundation for learning from error. This Web site supports an online portal facilitating incident reporting to enable data and experience analysis that will be used to inform development of guidelines and educational programs to promote safe practice in radiation oncology.

Cases & Commentaries

Monitoring Fetal Health

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

Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD; January 2015

A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient.

Journal Article > Commentary

A patient safety checklist for the cardiac catheterisation laboratory.

Cahill TJ, Clarke SC, Simpson IA, Stables RH. Heart. 2015;101:91-93.

Drawing from the success of the WHO surgical safety checklist initiative, this commentary describes the development of a checklist created to improve the reliability of core invasive cardiac procedures such as diagnostic angiography. The authors discuss the role of nurses in introducing the checklist and the use of team briefings to reduce the risk of communication errors. An example of the checklist tested is included.

Journal Article > Commentary

Saying "I'm sorry": error disclosure for ophthalmologists.

Lee BS, Gallagher TH. Am J Ophthalmol. 2014;158:1108-1110.

This commentary spotlights elements of ophthalmology practice that can influence error disclosure, particularly the prevalence of patients receiving care from optometrists outside the hospital environment with no central reporting mechanism.

Journal Article > Study

Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project.

Malicki J, Bly R, Bulot M, et al. Radiother Oncol. 2014;112:194-198.

This survey study found that safety practices for managing external beam radiotherapy vary among European countries. As with other safety concerns, adverse events are under-reported to voluntary reporting systems and root cause analysis of such incidents does not routinely occur. These results have clear implications for designing the planned intervention to improve the safety of external beam radiotherapy.

Cases & Commentaries

No BP During NIBP

  • Web M&M

Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MSc; September 2014

A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned.

Cases & Commentaries

Too Much, Too Fast

  • Web M&M

Delphine Tuot, MDCM, MAS; September 2014

A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful.

Journal Article > Commentary

New enteral connectors: raising awareness.

Guenter P. Nutr Clin Pract. 2014;29:612-614.

Redesigning tubing connectors according to new ISO standards has the potential to reduce tubing misconnections. This commentary provides information about changes to enteral connectors to prepare clinicians to use the new devices in their organizations.

Cases & Commentaries

Benefits vs. Risks of Intraosseous Vascular Access

  • Web M&M

Raymond L. Fowler, MD, and Melanie J. Lippmann, MD; July-August 2014

During a code blue, an intraosseous line was placed in the left tibia of an elderly woman after several unsuccessful attempts to obtain peripheral venous access. Following chest compressions and advanced cardiovascular life support protocol, spontaneous circulation returned and the patient was transferred to the intensive care unit. A few hours later, the left leg was dusky purple with sluggish distal pulses.

Cases & Commentaries

Liver Biopsy: Proceed With Caution

  • Web M&M

Don C. Rockey, MD; July-August 2014

Presenting with jaundice and epigastric pain, a woman with a history of multiple malignancies was admitted directly for an ultrasound-guided liver biopsy. After the procedure, the patient had low blood pressure and complained of new abdominal pain, which worsened over the next 2 hours. The bedside nurse soon found the patient unresponsive.

Journal Article > Study

Wrong-side thoracentesis: lessons learned from root cause analysis.

Miller KE, Mims M, Paull DE, et al. JAMA Surg. 2014;149:774-779.

Wrong-site procedures result in significant patient harm, and prior studies have shown that—contrary to traditional assumptions—many of these errors occur outside the operating room. This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified several common themes in these errors. The majority of errors resulted in serious patient injury. Root cause analysis of the errors found that clinicians often failed to perform a time out and did not correctly document laterality in consent forms and clinical records. A case of a wrong-side thoracentesis that resulted in the death of a patient is discussed in a previous AHRQ WebM&M commentary.

Journal Article > Study

Why don't nurses consistently take patient respiratory rates?

Ansell H, Meyer A, Thompson S. Br J Nurs. 2014;23:414-418.

Basic nursing care, such as measuring and recording vital signs, is often left undone. This qualitative study found that nurses frequently fail to accurately record patients' respiratory rates due to more urgent work tasks, confirming findings from prior studies.

Journal Article > Study

Training induces cognitive bias: the case of a simulation-based emergency airway curriculum.

Park CS, Stojiljkovic L, Milicic B, Lin BF, Dror IE. Simul Healthc. 2014;9:85-93.

This educational study found that anesthesiology residents were more likely to initiate an airway technique for which they had received simulation training, even if another technique (for which they received didactic training) would have been more appropriate. This finding demonstrates how training may inadvertently introduce cognitive bias.

Cases & Commentaries

New Oral Anticoagulants

  • Spotlight Case
  • Web M&M

Margaret C. Fang, MD, MPH; December 2013

Two days after knee replacement surgery, a woman with a history of deep venous thrombosis receiving pain control via epidural catheter was restarted on her outpatient dose of rivaroxaban (a newer oral anticoagulant). Although the pain service fellow scanned the medication list for traditional anticoagulants, he did not notice the patient was taking rivaroxaban before removing the epidural catheter, placing the patient at very high risk for bleeding.

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