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Approach to Improving Safety
- Communication Improvement 34
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Education and Training
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- Error Reporting and Analysis 21
- Human Factors Engineering 20
- Legal and Policy Approaches 6
- Logistical Approaches
- Quality Improvement Strategies 17
- Specialization of Care 4
- Teamwork 3
- Technologic Approaches 25
Safety Target
- Device-related Complications 1
- Diagnostic Errors 16
- Discontinuities, Gaps, and Hand-Off Problems 37
- Fatigue and Sleep Deprivation 10
- Identification Errors 5
- Interruptions and distractions 6
- Medical Complications 8
- Medication Safety 37
- Psychological and Social Complications 4
- Surgical Complications 8
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Search results for "Active Errors"
- Active Errors
- Logistical Approaches
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Journal Article > Study
Operational failures and interruptions in hospital nursing.
Tucker AL, Spear SJ. Health Serv Res. 2006;41:643-662.
This study discovered that nurses experienced more than eight work system failures during an 8-hour shift. Investigators combined primary observation with interview and survey methods to understand the role work system failures play on nurse effectiveness. The most frequent failures identified involved medications, orders, supplies, staffing, and equipment. In addition to operational failures that delayed productivity, a large number of reported work interruptions contributed to the study findings. The authors advocate for continued efforts to differentiate between tactics taken by bedside nurses to prevent error with tactics that result from the system (eg, interruptions), which often put patients at risk for error.
Cases & Commentaries
Delayed Recognition of a Positive Blood Culture
- Web M&M
Sarah Doernberg, MD, MAS; July 2017
A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.
Journal Article > Study
The impact of the 2011 Accreditation Council for Graduate Medical Education duty hour reform on quality and safety in trauma care.
Marwaha JS, Drolet BC, Maddox SS, Adams CA Jr. J Am Coll Surg. 2016;222:984-991.
Current studies suggest that the ACGME duty hours reform in 2011 did not substantially affect patient outcomes. Consistent with prior work, this retrospective cohort study found no differences in primary outcomes such as mortality. However, the authors suggest that future studies examine other quality metrics that may have changed after the duty-hours reform.
Journal Article > Study
Association of the 2011 ACGME resident duty hour reform with postoperative patient outcomes in surgical specialties.
Rajaram R, Chung JW, Cohen ME, et al. J Am Coll Surg. 2015;221:748-757.
This pre-post examination of data from the National Surgical Quality Improvement Program found no differences in serious morbidity or mortality within 30 days following surgery across multiple surgical specialties in the 2 years after 2011 ACGME duty hour reform, compared to the last year prior to reform. Although duty hour reform does not appear to be a high-yield strategy for improving surgical outcomes, concerns about worsening procedural skills and increased handoffs leading to patient harm were not borne out in the current data.
Cases & Commentaries
Critical Opportunity Lost
- Web M&M
Jonathan R. Genzen, MD, PhD, and Heather N. Signorelli, DO; March 2015
After presenting to the emergency department, a woman with chest pain was given nitroglycerine and a so-called GI cocktail. Her electrocardiogram was unremarkable, and she was scheduled for a stress test the next morning. A few minutes into the stress test, the patient collapsed and went into cardiac arrest.
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 > Commentary
Sleep deprivation: a call for institutional rules.
McKenna L, Kodner IJ, Healy GB, Keune JD. Surgery. 2013;154:118-122.
This commentary illustrates the ethics around three potential tactics to address surgeons with fatigue.
Newspaper/Magazine Article
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
Describing an adverse event involving patient-controlled analgesia (PCA), this newsletter article highlights risks around PCA use and recommends practices to enhance monitoring and prevent accidental overdose.
Newspaper/Magazine Article
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.
This newsletter article discusses factors that contributed to the death of a patient in an ambulatory surgery center and recommends improved monitoring practices and alarm management in post-anesthesia care units.
Journal Article > Commentary
Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.
DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-410.
Reviewing evidence on transitions in care, this article describes how one university health system developed a comprehensive handoff curriculum to address educational needs in the context of changes to resident duty hours.
Cases & Commentaries
Amended Lab Results: Communication Slip
- Web M&M
Vanitha Janakiraman Mohta, MD; February 2012
A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.
Perspectives on Safety > Perspective
Balancing Supervision and Autonomy: An Ongoing Tension
with commentary by C. Jessica Dine, MD, MA; and Jennifer S. Myers, MD, Resident Supervision and Patient Safety, February 2012
This piece discusses how increased supervision influences the educational experience for trainees.
Journal Article > Commentary
Incomplete care—on the trail of flaws in the system.
Gandhi TK, Zuccotti G, Lee TH. N Engl J Med. 2011;365:486-488.
This article describes how missing patient information and disregarded reminders in electronic medical records can contribute to errors in care.
Cases & Commentaries
A Seasonal Care Transition Failure
- Web M&M
John Q. Young, MD, MPP; July 2011
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
Newspaper/Magazine Article
Entire UPMC transplant team missed hepatitis alert.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Newspaper/Magazine Article
Medical misdiagnoses can have fatal consequences.
Olsen D. State Journal-Register. June 26, 2011.
This newspaper article discusses a case of diagnostic error, explores the complexity of the diagnostic process, and provides tips to help patients avoid such errors.
Cases & Commentaries
Outbreak
- Web M&M
Richard Rothman, MD, PhD; Sahael Stapleton, MD; May 2011
An emergency department worker develops chicken pox following an exposure during one of his shifts.
Journal Article > Commentary
A 60-year-old man with delayed care for a renal mass.
Schiff GD. JAMA. 2011;305:1890-1898.
Clinical Crossroads is a popular series in the Journal of the American Medical Association (JAMA) that highlights patient and provider perspectives in common clinical scenarios. This article discusses a patient who experienced delays in care due to a myriad of system failures in the ambulatory setting. The invited discussant explores the causes of these failures and discusses situational awareness, improved handoffs, and fostering a culture of safety. Emerging test management systems and critical test follow-up practices are key elements of proposed improvements. The fact that JAMA chose a clinical scenario focusing on systems failures mirrors past efforts in the Annals of Internal Medicine and the New England Journal of Medicine to spotlight patient safety—all noteworthy events for such high impact journals.
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.
Journal Article > Study
Do staffing levels predict missed nursing care?
Kalisch BJ, Tschannen D, Lee KH. Int J Qual Health Care. 2011;23:302-308.
This study surveyed nurses and discovered that inadequate nurse staffing levels may partly explain gaps in required nursing care for patients.