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Search results for "Active Errors"

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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 > Study

Outcome of 6 years of protocol use for preventing wrong site office surgery.

Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.

This study describes the use of a tool to prevent wrong site procedures in a dermatologic surgery setting.

Journal Article > Study

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.

Journal Article > Commentary

Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery.

Lutgendorf MA, Schindler LL, Hill JB, Magann EF, O'Boyle JD. Mil Med. 2011;176:702-704.

This commentary discusses the development and implementation of a count procedure that successfully reduced incidence of retained sponges following labor and delivery.

Journal Article > Study

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

Chan J, Shojania KG, Easty AC, Etchells EE. J Am Med Inform Assoc. 2011;18:276-281.

A user-centered design format for computerized provider order entry order sets proved to be more efficient and usable than standard formats, with no difference in prescribing error rates.

Newspaper/Magazine Article

Another tragic parenteral nutrition compounding error.

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

This article analyzes a fatal error involving parenteral nutrition and makes recommendations to prevent such incidents.

Newspaper/Magazine Article

MGH faces suit over drug error that killed woman.

Valencia MJ. Boston Globe. March 10, 2011.

This newspaper article reports on a fatal medication error involving an anticoagulant overdose.

Journal Article > Study

Trauma resuscitation errors and computer-assisted decision support.

Fitzgerald M, Cameron P, Mackenzie C, et al. Arch Surg. 2011;146:218-225.

Accurate initial assessment and resuscitation of trauma patients is critical to ensuring correct treatment and survival, and although standardized algorithms have been developed for initial trauma evaluation, errors are not uncommon. This innovative randomized controlled trial implemented a computerized clinician decision support system (CDSS) to ensure adherence to standardized protocols for trauma resuscitation, and used video capture of trauma resuscitations to assess the effects of the CDSS on patient outcomes. Use of the CDSS resulted in significantly reduced errors, and also reduced morbidity compared to standard treatment. This study demonstrates the utility of a CDSS in a fast-paced, high-acuity environment.

Newspaper/Magazine Article

A pinpoint beam strays invisibly, harming instead of healing.

Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.

This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.

Cases & Commentaries

The Forgotten Turn

  • Spotlight Case
  • Web M&M

Susan Barbour, RN, MS, FNP; December 2010

Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.

Journal Article > Commentary

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

This protocol is designed to protect against wrong-site incidents in ambulatory care and to improve team communication and patient engagement.

Cases & Commentaries

Acute Respiratory Arrest in Pregnancy

  • Web M&M

Baha Sibai, MD; June 2010

A woman with chronic hypertension developed undiagnosed preeclampsia during pregnancy with twins. At 38 weeks, she experienced respiratory and cardiac arrest. Although she eventually recovered, the infants were stillborn.

Cases & Commentaries

Anticoagulation: Held Too Long

  • Web M&M

Andrew S. Dunn, MD; April 2010

An elderly woman with a history of mitral valve replacement with a mechanical prosthesis was admitted to the hospital for evaluation of abdominal pain. Although an order was written to stop her blood thinner and restart it 48 hours after the procedure, the medication was not restarted.

Journal Article > Study

Reducing inappropriate diagnostic practice through education and decision support.

Bairstow PJ, Persaud J, Mendelson R, Nguyen L. Int J Qual Health Care. 2010;22:194-200.

A decision support program improved adherence to recommended diagnostic algorithms for common emergency department conditions.

Journal Article > Study

Safety as a criterion for quality: The Critical Nursing Situation Index in paediatric critical care, an observational study.

de Neef M, Bos AP, Tol D. Intensive Crit Care Nurs. 2009;25:341-347.

This study describes the Critical Nursing Situation Index (CNSI), an observational tool that identifies deviations from safe practice, and focuses on potential nursing errors before they occur.

Cases & Commentaries

Missing Trauma

  • Web M&M

Gregory J. Jurkovich, MD; May 2009

After an hour of failed resuscitative efforts, a woman who collapsed in a market is pronounced dead in the emergency department (ED). Only later do the paramedics and physician discover a small bullet in the patient's chest.

Newspaper/Magazine Article

Beware of basal opioid infusions with PCA therapy.

ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.

This article provides screening, dosing, and monitoring recommendations for using basal opioid infusions and patient-controlled analgesia (PCA) in patients at risk for developing respiratory depression.

Cases & Commentaries

Are Two Insulin Pumps Better Than One?

  • Web M&M

Curtiss B. Cook, MD; January 2009

Admitted to the hospital for surgery, a man with type 1 diabetes mellitus asked the staff to leave his home insulin pump in place but did not mention that he was adjusting his insulin pump himself based on serial glucose measurements. As the patient was also receiving an intravenous insulin infusion, he developed hypoglycemia.

Cases & Commentaries

A Mid-Summer Fog

  • Web M&M

Clarence H. Braddock III, MD, MPH; November 2008

A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.

Journal Article > Study

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

Pham JC, Story JL, Hicks RW, et al. J Emerg Med. 2011;40:485-492.

A 2006 Institute of Medicine report highlighted growing concerns about the state of emergency department (ED) care, particularly around overcrowding and its impact on safety. Medication errors are a known safety threat, and this study provides a cross-sectional perspective using reports from the MEDMARX database. Investigators found that physicians were responsible for 24% of errors while nurses were responsible for 54%. The administration phase was the most error-prone, and the most common error type was improper dose/quantity. Interestingly, computerized provider order entry was noted to cause 2.5% of the errors reported. The authors advocate for future interventions to improve medication safety in the ED. A past AHRQ WebM&M commentary discussed a near miss medication error in the ED that illustrates the many safety issues that contribute to this high-risk care setting.

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