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Search results for "Active Errors"

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Meeting/Conference > Massachusetts Meeting/Conference

Improving Patient Safety With Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 26–27, 2017; Constellation Energy Building, Baltimore, MD.

This two-day workshop will discuss of how human factors engineering methods can be applied to identify risks, augment the work environment, and evaluate technology to address potential system failures in health care. 

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 > Study

Electronic detection of delayed test result follow-up in patients with hypothyroidism.

Meyer AND, Murphy DR, Al-Mutairi A, et al. J Gen Intern Med. 2017;32:753-759.

Trigger tools facilitate identification of adverse events. In this retrospective medical record review study, investigators found that an automated trigger successfully identified delayed follow-up of laboratory thyroid testing among patients with hypothyroidism, with a positive predictive value of 60%. The authors suggest that this trigger approach could be used to detect and ameliorate follow-up delays in real time.

Journal Article > Commentary

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

Journal Article > Study

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial.

Bhattacharya D, Aldus CF, Barton G, et al. Health Technol Assess. 2016;20:1-250.

Medication organization devices provide compartments to help sort patients' medications by days of the week and are thought to improve medication safety. Assessing patients age 75 and older who were prescribed three or more oral medications, this feasibility study found that medication adherence did not improve among those given medication organization devices compared to those using standard medication dispensing. The authors note that many potentially eligible participants were excluded because they already used such devices and suggest that future studies target a younger age range.

Cases & Commentaries

A Room Without Orders

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

Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN; January 2016

Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.

Book/Report

The Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola Events.

  • Classic

Cortese D, Abbott P, Chassin M, Lyon GM III, Riley WJ. Dallas, TX: Texas Health Resources Leadership; 2015.

Delayed diagnosis of infectious disease can negatively affect patients, care teams, and public health. Reviewing insights from a panel analysis of the well-known incident involving delayed diagnosis of Ebola virus, this report highlights the need to improve information transfer and emergency department safety culture to enhance diagnostic and infection prevention processes.

Cases & Commentaries

Dual Therapy Debacle

  • Web M&M

Steven R. Kayser, PharmD; September 2015

Following a myocardial infarction, an elderly man underwent percutaneous coronary intervention and had two drug-eluting stents placed. He was given triple anticoagulation therapy for 6 months, with a plan to continue dual anticoagulation therapy for another 6 months. Although the primary care provider saw the patient periodically over the next few years, the medications were not reconciled and the patient remained on the dual therapy for 3 years.

Journal Article > Study

Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry.

Idemoto LM, Williams BL, Ching JM, Blackmore CC. Am J Health Syst Pharm. 2015;72:1481-1488.

This study examined the effect of a custom alert intended to reduce medication-timing errors associated with introduction of computerized provider order entry, which can lead to too-frequent or missed doses of medications. Using a rigorous interrupted time-series design, researchers found fewer medication-timing errors after implementation of this alert. This work demonstrates how custom alerts developed by clinicians can harness the electronic health record to improve safety.

Journal Article > Commentary

A piece of my mind. Writing the wrong.

Patel JJ. JAMA. 2015;314:671-672.

Despite the potential for electronic health record (EHR) systems to improve access to patient data, unintended consequences have emerged that can hinder information seeking. To highlight how EHRs can detract from patient–physician relationships, this commentary reveals insights from a physician who failed to notice a patient's respiratory failure and distress due to over-reliance on the EHR.

Press Release/Announcement

ISMP Survey on Implementation of the 2016–2017 Targeted Medication Safety Best Practices for Hospitals.

Horsham, PA: Institute for Safe Medication Practices. 

This survey seeks to assess the implementation of consensus-based best practices to improve medication safety in health care facilities. The deadline for submitting responses is July 21, 2017.

Journal Article > Study

Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.

Murphy DR, Thomas EJ, Meyer AND, Singh H. Radiology. 2015;277:81-87.

Delays in follow-up of abnormal test results are known to contribute to delayed and missed diagnosis. Investigators developed and validated an electronic trigger to identify potential delays in follow-up of abnormal chest computed tomography scans. This study found that more than half of the flagged cases had a true diagnostic delay. This work should lead to prospective evaluation of trigger approaches to enhance test result follow-up.

Journal Article > Commentary

Transforming communication and safety culture in intrapartum care: a multi-organization blueprint.

Lyndon A, Johnson MC, Bingham D, et al. Obstet Gynecol. 2015;125:1049-1055.

Poor communication among perinatal health care teams has been highlighted as a safety concern. Exploring human factors, leadership behaviors, and root causes that may contribute to miscommunication, this commentary recommends ways individual clinicians, team leaders, managers, organizations, and patients and their families can enhance safety in the labor and delivery setting.

Journal Article > Review

A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.

Johnston MJ, Arora S, King D, et al. Surgery. 2015;157:752-763.

Failure to rescue—lack of adequate response to patient deterioration—has been associated with adverse patient outcomes, particularly in acute care settings. This systematic review found that high hospital volume and increased patient-to-nurse staffing ratios were associated with failure to rescue, suggesting that addressing these workforce issues may enhance ability to recognize and intervene for deteriorating patients.

Journal Article > Study

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record.

Dalal AK, Pesterev BM, Eibensteiner K, Newmark LP, Samal L, Rothschild JM. J Am Med Inform Assoc. 2015;22:905-908.

Failure to follow-up on test results in ambulatory practice is a common, serious safety concern. This study examined the use of a results manager tool by primary care physicians in Partners Healthcare in Boston. Although the vast majority of providers used the tool, many did not find that it was helpful for any specific purpose and only 64% were satisfied with the tool.

Audiovisual > Audiovisual Presentation

Patient Safety Essentials for Laboratory Professionals Certificate Program.

Washington, DC: American Association for Clinical Chemistry.

This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.

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.

Web Resource > Multi-use Website

Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital.

American Society of Health-System Pharmacists.

Insulin is classified as a high-alert medication due to the potential to cause serious patient harm when administered incorrectly. This Web site provides information and resources related to an initiative aimed at augmenting pharmacist education about appropriate use of insulin and insulin pens in the hospital setting.

Journal Article > Study

The effect of an electronic checklist on critical care provider workload, errors, and performance.

Thongprayoon C, Harrison AM, O'Horo JC, Sevilla Berrios RA, Pickering BW, Herasevich V. J Intensive Care Med. 2016;31:205-212.

Simulation has been advocated as a way to create a safe space to learn from error. This simulation-based study found that electronic checklists used by intensivists reduced workload and errors compared to paper checklists, adding to the evidence supporting checklist use in medical care.

Newspaper/Magazine Article

Strengthen your resolve: no unlabeled containers anywhere, ever!

ISMP Medication Safety Alert! Acute Care Edition. November 6, 2014;19:1-4.

Despite the designation of proper labeling as a National Patient Safety Goal in 2006, the problem of unlabeled solutions and medications persists. This newsletter article outlines several incidents involving labeling issues that contributed to patient harm or death and provides strategies to reduce risks related to poor labeling practices, including ensuring labels are available in all settings that require them, using tall man lettering to differentiate look-alike drug names, and limiting access to solutions and medications.

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