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Approach to Improving Safety
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Search results for "Active Errors"

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Newspaper/Magazine Article

The last person you'd expect to die in childbirth.

Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.

Maternal mortality is increasing in the United States. This news article reports on this critical safety problem in the context of the preventable death of a patient whose diagnosis of preeclampsia was missed by her providers, despite persistent concerns raised by family about the patient's symptoms.

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.

Cases & Commentaries

Diagnosing a Missed Diagnosis

  • Web M&M

James B. Reilly, MD, MS, and Christopher Webster, DO; March 2017

A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.

Newspaper/Magazine Article

Can computers help doctors reduce diagnostic errors?

Shryock T. Med Econ. December 5, 2016.

Computerized decision support and advanced computing are being used to augment various processes in health care, such as medication ordering and diagnosis. This magazine article reports on the accuracy of these systems and the potential role of artificial intelligence in supporting diagnostic decision making.

Journal Article > Commentary

The causes of errors in clinical reasoning: cognitive biases, knowledge deficits, and dual process thinking.

Norman GR, Monteiro SD, Sherbino J, Ilgen JS, Schmidt HG, Mamede S. Acad Med. 2017;92:23-30.

Decision making is typically either intuitive or analytical. This commentary discusses the two types of decision making, how heuristics and cognitive biases affect diagnostic reasoning, and strategies to reduce diagnostic error.

Meeting/Conference > Massachusetts Meeting/Conference

Diagnostic Error in Medicine 10th International Conference.

Society to Improve Diagnosis in Medicine. October 8-10, 2017, Boston Marriott Newton, Newton MA.

This annual conference will focus on the theme, "Improving Diagnosis: It Takes a Team" to drive work in reducing diagnostic errors. Featured speakers include Dr. Donald Berwick, Professor Amy Edmondson and Dr David Mayer.

Journal Article > Study

Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.

Dowell D, Zhang K, Noonan RK, Hockenberry JM. Health Aff (Millwood). 2016;35:1876-1883.

Opioid-related harm, including overdose deaths, has reached epidemic proportions. This study used a difference-in-differences analysis to examine whether a policy approach could reduce harm from opioid misuse. Investigators compared states with and without mandated provider review of drug monitoring data. In states with mandated review, opioid prescribers must check whether patients are receiving opioids from multiple prescribers and identify the total prescribed opioid dose. States with mandated review policies had fewer opioid overdose deaths and lower amounts of opioids prescribed than states without mandated prescriber review. These results are consistent with a prior study that established the benefit of prescription drug monitoring programs. The authors assert that despite the effectiveness of this policy, more interventions are needed to enhance opioid safety, as suggested in a recent study. A previous WebM&M commentary described opioid-related harm.

Meeting/Conference > Government Resource

AHRQ Research Summit on Improving Diagnosis in Health Care.

Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.

Research is increasingly focusing on diagnostic errors and strategies to reduce them. This conference explored the science behind diagnosis and discuss the research, tactics, and tools needed to enhance diagnostic performance.

Newspaper/Magazine Article

When doctors get the wrong patient.

Whitman E. Mod Healthc. September 25, 2016.

Misidentification of patients can result in problems such as medication administration delays, blood transfusion mismatches, and wrong-patient surgery. This magazine article reviews recent research on this issue and suggests several system approaches for improvement, including the use of patient photos in electronic health records and standardizing patient identification processes.

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 > Commentary

Preventing diagnostic errors in primary care.

Ely JW, Graber ML. Am Fam Physician. 2016;94:426-432.

The Improving Diagnosis in Health Care report advocated for enhancing patient engagement as a strategy to reduce diagnostic error. This commentary suggests that discussing uncertainty, seeking second opinions, and utilizing a checklist to guide decision-making can help engage primary care patients in the diagnostic process.

Cases & Commentaries

A Pill Organizing Plight

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

Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD; September 2016

An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.

Cases & Commentaries

Wrong-Time Error With High-Alert Medication

  • Web M&M

Annie Yang, PharmD, and Lewis Nelson, MD; September 2016

Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.

Journal Article > Review

The global burden of diagnostic errors in primary care.

Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. BMJ Qual Saf. 2017;26:484-494.

The need to improve diagnosis is gaining international recognition. This review summarizes the literature on diagnostic error in primary care and recommends policy and research strategies to prioritize changes needed to enhance diagnostic safety globally.

Newspaper/Magazine Article

A better safety net for young doctors.

Landro L. Wall Street Journal. August. 8, 2016.

First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.

Journal Article > Review

Context-sensitive decision support (infobuttons) in electronic health records: a systematic review.

Cook DA, Teixeira MT, Heale BSE, Cimino JJ, Del Fiol G. J Am Med Inform Assoc. 2017;24:460-468.

Infobuttons, a form of clinical decision support, are small icons in the electronic health record that allow users to access online knowledge resources. This systematic review found some evidence that infobuttons may be helpful despite infrequent use. The authors advocate for further research to determine optimal design and implementation of infobuttons in electronic health records.

Journal Article > Study

Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study.

van Welie S, Wijma L, Beerden T, van Doormaal J, Taxis K. BMJ Open. 2016;6:e012286.

Not all pill-form medications can be safely crushed to administer to patients who have difficulty swallowing. In this before and after intervention study in a nursing home, adding warning symbols and educating staff about crushing medications led to a decrease in pill-crushing errors. The authors conclude that education and warnings enhanced this aspect of medication safety.

Journal Article > Review

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.

Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.

Book/Report

Avoiding Unconscious Bias: a Guide for Surgeons.

London, UK: Royal College of Surgeons of England; 2016.

Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.

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