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Search results for "Active Errors"

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Journal Article > Study

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.

Sharma M, Krishnamurthy M, Snyder R, Mauro J. Clin Pract. 2017;7:953.

Anticoagulants are considered high-risk medications due to their narrow therapeutic window and association with adverse drug events. This study suggests that integration of a clinical pharmacist into the inpatient team may help prevent anticoagulation dosing errors and resultant harm to patients.

Journal Article > Study

Extent of diagnostic agreement among medical referrals.

Van Such M, Lohr R, Beckman T, Naessens JM. J Eval Clin Pract. 2017 Apr 4; [Epub ahead of print].

Diagnostic uncertainty is common and can lead to missed or delayed diagnoses. This retrospective medical record review study examined cases where primary care providers sought diagnostic input from subspecialists. Investigators compared the final diagnosis from the subspecialty visit with the presumed diagnosis at the time of the initial subspecialty referral. They found that the diagnosis differed substantially in about one-fifth of cases following the subspecialty consultation. Costs were higher for cases with substantively different diagnoses compared to cases where subspecialists confirmed or further clarified diagnoses. The authors conclude that subspecialty access is critical to timely and accurate diagnosis. A recent WebM&M commentary discussed how cognition can influence diagnostic decision making.

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.

Journal Article > Review

Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review.

Albutt AK, O'Hara JK, Conner MT, Fletcher SJ, Lawton RJ. Health Expect. 2016 Oct 26; [Epub ahead of print].

This systematic review examined whether patient and family member activation of rapid response teams improved recognition of clinical deterioration. Studies demonstrated that patients and family members did not overwhelm rapid response capacity with frequent activations, but they did activate rapid response to convey concerns beyond clinical deterioration. The authors suggest further study is needed to determine how to best engage patients and families to detect clinical deterioration early.

Journal Article > Study

Opportunities to enhance laboratory professionals' role on the diagnostic team.

Taylor JR, Thompson PJ, Genzen JR, Hickner J, Marques MB. Lab Med. 2017;48:97-103.

Diagnostic error represents a significant source of patient harm. In this study, researchers surveyed physicians to understand how to improve the involvement of laboratory professionals in assisting with diagnostic challenges. They conclude that there may be a greater role for laboratory professionals in the diagnostic process beyond providing test results.

Journal Article > Study

Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens.

Tong EY, Roman C, Mitra B, et al. J Clin Pharm Ther. 2016;41:414-418.

Medication discrepancies during hospital admission are common and can lead to preventable harm. This study examined the impact of having a pharmacist review medical charts of patients with complex medication regimens who were admitted to a general medical or emergency short-stay unit. The authors found that partnering medical staff with a pharmacist to review patients' admission medications in the chart significantly decreased inpatient medication errors.

Journal Article > Review

Medication safety systems and the important role of pharmacists.

Mansur JM. Drugs Aging. 2016;33:213-221.

Preventing adverse drug events is a major priority for accrediting and regulatory agencies. This review describes a framework for medication safety systems, including design considerations to integrate safety across the medication use process and unique roles for clinical pharmacists. Elements of the framework address risk awareness, barriers to error reporting, and the need to utilize performance improvement methods.

Journal Article > Study

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

Hughes KM, Goswami ES, Morris JL. J Pediatr Pharmacol Ther. 2015;20:453-461.

Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.

Journal Article > Review

Interventions for reducing medication errors in children in hospital.

Maaskant JM, Vermeulen H, Apampa B, et al. Cochrane Database Syst Rev. 2015;3:CD006208.

Exploring the literature on efforts to reduce medication errors in hospitalized children, this systematic review examined five interventions, including introduction of computerized provider order entry systems, clinical pharmacist participation in the frontline care team, and implementation of barcode medication administration systems. Although the interventions showed some success, none of the studies found a significant reduction in patient harm.

Journal Article > Study

Detection of missed injuries in a pediatric trauma center with the addition of acute care pediatric nurse practitioners.

Resler J, Hackworth J, Mayo E, Rouse TM. J Trauma Nurs. 2014;21:272-275.

Missed injuries and delayed diagnoses are a relatively common problem in trauma care. This study describes a 150% increase in the number of documented missed injuries that were caught following the introduction of acute care nurse practitioners on a pediatric trauma service. The authors attribute the uptick in identified missed injuries to better charting and follow-up examinations.

Journal Article > Study

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

Shaw RE, Litman RS. Jt Comm J Qual Patient Saf. 2014;40:471-475.

In 2010, the Anesthesia Patient Safety Foundation recommended that hospital pharmacies supply premixed solutions or prefilled syringes of commonly used anesthetic medications. Despite this recommendation, this convenience sample of 34 children's hospitals across the United States found that the majority of medications administered by anesthesiologists in 2012 were still prepared by the provider at the bedside.

Journal Article > Commentary

Improving safety and quality of care with enhanced teamwork through operating room briefings.

Hicks CW, Rosen M, Hobson DB, Ko C, Wick EC. JAMA Surg. 2014;149:863-868.

Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site surgery. This commentary explores the use of briefings both before and after surgery, evidence regarding their impact, and how a comprehensive unit-based safety program (CUSP) initiative designed and implemented a briefing and debriefing process.

Audiovisual

Hospitals put pharmacists in the ER to cut medication errors.

Silverman L. Morning Edition. National Public Radio. June 9, 2014.

This radio segment discusses the experience of a pediatric medical center that hired pharmacists for its emergency department to review medication orders before the medicine is dispensed and administered in an effort to prevent medication errors.

Journal Article > Study

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013.

Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2014;71:924-942.

This national survey of inpatient pharmacy directors found that most hospitals maintain strict control of medication formularies, and direct pharmacist involvement in inpatient care is growing. Electronic prescribing was reported to occur in the majority of outpatient clinics and hospitals. A past AHRQ WebM&M perspective discussed how expanding the role of pharmacists has the potential to improve safety.

Journal Article > Study

Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.

  • Classic

Johnston M, Arora S, King D, Stroman L, Darzi A. Surgery. 2014;155:989-994.

This interview study examined escalation of care, the process by which a patient's deteriorating clinical status is recognized and acted upon, among surgical patients. Attending surgeons, trainees, intensivists, and rapid response team members believe that protocols for escalation of care lack clarity and that there is a dearth of supervision from senior clinicians. Similar to studies of handoffs, direct conversation—either in person or via mobile phone—was deemed preferable to hospital paging systems. Participants identified communication training, explicit and clear protocols, and increased supervision as key to improving the care of deteriorating surgical patients. Accompanying editorials highlight the importance of communication and the need for a safety culture that supports multidisciplinary teams.

Journal Article > Review

Using pharmacists to optimize patient outcomes and costs in the ED.

Jacknin G, Nakamura T, Smally AJ, Ratzan RM. Am J Emerg Med. 2014;32:673-677.

Exploring factors that increase risk of medication-related errors in the emergency department, this review describes the benefits of incorporating clinical pharmacists in the frontline care team, including real-time monitoring, discussion, and education about medication prescribing and use of substitute drugs.

Journal Article > Study

The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study.

Nguyen HT, Pham HT, Vo DK, et al. BMJ Qual Saf. 2014;23:319-324.

An educational program that included lectures, ward-based teaching sessions, and protocols significantly decreased the rate of intravenous medication errors in an intensive care unit in Vietnam. However, clinically significant errors still occurred in nearly half of all medication administrations (down from 64% pre-intervention).

Journal Article > Review

Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis.

Niven DJ, Bastos JF, Stelfox HT. Crit Care Med. 2014;42:179-187.

Formal transition programs for patients being discharged from the intensive care unit (ICU) to general wards, which generally involved proactive surveillance by a nurse or physician, were associated with a decreased risk of readmission to the ICU.

Journal Article > Study

Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.

Taylor AM, Chuo J, Figueroa-Altmann A, DiTaranto S, Shaw KN. Jt Comm J Qual Patient Saf. 2013;39:396-403.

Leadership WalkRounds—derived from the business management approach of "management by walking around"—are being more widely used as a means of error detection and improving safety culture. This report from a children's hospital, in which structured walkrounds by nursing and physician leaders were implemented on six units, found that this approach increased staff engagement in safety efforts, identified hidden system flaws, and resulted in the successful implementation of multiple quality improvement projects. Although this study did not specifically measure the effect of walkrounds on safety climate, prior studies have found conflicting results, which might imply that different methods of performing walkrounds may influence their success.

Cases & Commentaries

Pocket Syringe Swap

  • Web M&M

John C. Kulli, MD; May 2011

A surgery fellow put two syringes in his pocket: one containing leftover anesthetic and one with agents to reverse it. When it came time to reverse the neuromuscular block, he administered the anesthetic by mistake.

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