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Search results for "Active Errors"

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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

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

Mody L, Greene MT, Meddings J, et al. JAMA Intern Med. 2017 May 19; [Epub ahead of print].

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

Journal Article > Commentary

Farewell to a cancer that never was.

Lyon J. JAMA. 2017;317:1824-1825.

Overdiagnosis can result in financial, psychological, and physical harm for patients. This commentary discusses the reclassification of a subtype of thyroid cancer as a nonmalignancy and the impact changing guidelines can have on patients.

Journal Article > Study

Evaluating serial strategies for preventing wrong-patient orders in the NICU.

Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139:e20162863.

Wrong-patient errors are a well-established risk in the health care setting. Research has shown that providers, often multitasking, may enter notes or medication orders for the wrong patient. A prior study touted point-of-care photographs as a helpful intervention for identifying and preventing wrong-patient errors in a cardiothoracic intensive care unit. However, less is known about wrong-patient errors in the neonatal intensive care unit (NICU) population and ways to prevent them. Researchers analyzed more than 850,000 NICU orders and more than 3.5 million non-NICU orders in pediatric patients over a 7-year period. At baseline, they found that wrong-patient orders occurred more frequently in the NICU population with an odds ratio of 1.56. Interventions included requiring reentry of patient identifiers prior to order entry as well as a new naming system for newborns. Implementation of both led to a 61.1% reduction in wrong-patient errors in the NICU population from baseline. A previous WebM&M commentary highlights a case of wrong-patient identification.

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

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Cases & Commentaries

The Empty Bag

  • Web M&M

Chris Vincent, PhD; December 2016

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

Book/Report

Global Guidelines on the Prevention of Surgical Site Infection.

Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.

Journal Article > Commentary

Measures to improve diagnostic safety in clinical practice.

Singh H, Graber ML, Hofer TP. J Patient Saf. 2016 Oct 20; [Epub ahead of print].

Efforts to reduce diagnostic errors are hindered by the lack of effective measures to track improvement. This commentary proposes a set of measures for consideration that have the potential to structure research and evaluation of diagnosis improvement initiatives.

Special or Theme Issue

Insulin Pens Devices.

Am J Health Syst Pharm. 2016;73(19 suppl 5);S1-S47.

As a high-alert medication, insulin has the potential to result in serious patient harm if administered incorrectly. Articles in this special issue discuss recommendations developed to address risks associated with pen injector practices and the results of an improvement initiative to enhance the safe use of insulin pens. Mentoring and safety culture are highlighted as areas that support improvements.

Book/Report

Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.

Boutwell A, Bourgoin A , Maxwell J, DeAngelis K, Genetti S, Savuto M, Snow J. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No.16-0047-EF.

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

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.

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.

Journal Article > Commentary

Improving the communication between teams managing boarded patients on a surgical specialty ward.

Puvaneswaralingam S, Ross D. BMJ Qual Improv Rep. 2016;5.

Boarding patients as they transfer between wards can compromise patient safety. This commentary reviews how an otolaryngology ward implemented a simple cognitive aid to improve patient record review, information sharing, and team communication. The authors report the results of the project and how they intend to use plan-do-study-act cycles to refine the process.

Journal Article > Commentary

Access to prescription opioids—Primum Non Nocere: a teachable moment.

Tyler PD, Larochelle MR, Mafi JN. JAMA Inter Med. 2016;176:1251-1252.

Insufficient medication counseling and suboptimal prescribing practices contribute to misuse of opioids among patients. Describing a patient who became addicted to prescription opioids as a teenager after finding the medication at home, this commentary illustrates how current prescribing guidelines can address the opioid epidemic in the United States.

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.

Newspaper/Magazine Article

Correct use of inhalers: help patients breathe easier.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.

Patients and clinicians can make medication administration mistakes when new drug delivery mechanisms are introduced. This newsletter article reviews common errors associated with the use of inhalers and offers recommendations for patients, nurses, respiratory therapists, pharmacists, and health care organizations to educate patients on the use of these medications.

Journal Article > Commentary

Getting it right for patient safety: specimen collection process improvement from operating room to pathology.

D'Angelo R, Mejabi O. Am J Clin Pathol. 2016;146:8-17.

Mistakes in laboratory specimen labeling can contribute to diagnostic delay and error. This commentary describes an improvement initiative that enhanced teamwork between a pathology and surgical unit and applied Lean methodologies to redesign specimen labeling processes and reduce errors and inefficiencies over a 2-year period.

Journal Article > Commentary

Guideline implementation: prevention of retained surgical items.

Fencl JL. AORN J. 2016;104:37-48.

Although incidents involving retained surgical items are rare, they continue to occur. This commentary reviews guidance for perioperative nurses to reduce risks of this sentinel event. The author outlines steps to improve safety such as team accountability, standardized surgical sponge counts, and reconciling count discrepancies.

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