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Approach to Improving Safety
- Communication Improvement 18
- Culture of Safety 2
- Education and Training 5
- Error Reporting and Analysis 5
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Logistical Approaches
- Quality Improvement Strategies 8
- Specialization of Care 1
- Technologic Approaches 14
Safety Target
Clinical Area
- Medicine 25
- Nursing 2
- Pharmacy 2
Target Audience
Search results for "Active Errors"
- Active Errors
- Laboratory Result Tracking Improvement
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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.
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.
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.
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.
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.
Cases & Commentaries
Failure to Reevaluate
- Web M&M
Annie Wong-Beringer, PharmD; December 2010
A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.
Cases & Commentaries
Treatment Challenges After Discharge
- Spotlight Case
- Web M&M
Chase Coffey, MD, MS; November 2010
A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.
Newspaper/Magazine Article
Diagnostic error in acute care.
PA-PSRS Patient Saf Advis. 2010;7:76-86.
Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.
Journal Article > Study
Errors of diagnosis in pediatric practice: a multisite survey.
Singh H, Thomas EJ, Wilson L, et al. Pediatrics. 2010;126:70-79.
A considerable number of patients suffer preventable harm due to diagnostic errors every year. Our knowledge of underlying causes of missed diagnoses, and the types of diagnoses that are often missed, are largely based on autopsy studies and data from malpractice claims, which may over-represent diagnoses that cause death or serious disability. The 1300 pediatricians and pediatric trainees surveyed in this study identified misdiagnosis of viral illnesses as bacterial infections and failure to recognize medication side effects as the most common types of diagnostic error. Faulty information gathering and suboptimal communication were named as the principal individual and system factors leading to diagnostic error. Physicians named closer follow-up and reliable test management systems as major system improvements that could reduce the risk of diagnostic error.
Journal Article > Study
Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.
Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.
This study found a significant reduction in mislabeled blood specimens after implementing barcode technology.
Journal Article > Study
The management of test results in primary care: does an electronic medical record make a difference?
Elder NC, McEwen TR, Flach J, Gallimore J, Pallerla H. Fam Med. 2010;42:327-333.
Electronic health records (EHRs) hold great promise for improving patient safety, but remain underutilized, especially in ambulatory care settings. Failure to appropriately follow up on abnormal test results is a common ambulatory care safety problem, and has been implicated in malpractice lawsuits arising from missed or delayed diagnoses. In this study conducted at eight family medicine clinics, those with an EHR documented clinician and patient notification of abnormal test results and clear follow-up plans more often than those with paper charts. However, even in clinics using EHRs, more than one-third of abnormal results had no follow-up plan documented. This finding corroborates prior research that clinician notification alone does not ensure timely and complete follow-up of test results.
Meeting/Conference
Diagnostic Error in Medicine.
Berner ES, Graber ML, eds. Adv Health Sci Educ Theory Pract. 2009;14(suppl 1):1-112.
This supplement consists of 12 articles drawn from a 2008 conference on diagnostic error, covering topics such as medical problem solving, clinical decision making, diagnostic decision support systems, and educational approaches to reducing diagnostic errors.
Cases & Commentaries
Is the Admission Drug Dose Too Low?
- Web M&M
Rainu Kaushal, MD, MPH; Erika Abramson, MD ; August 2009
The theophylline dose of a patient admitted for COPD exacerbation and pneumonia is doubled, and he develops atrial flutter with a rapid ventricular response, chest pain, and increased shortness of breath.
Perspectives on Safety > Perspective
Patient Safety: A Perspective from Office Practice
with commentary by Richard J. Baron, MD, The Business Case for Improving Safety, May 2009
Most patient interactions with the health care system occur in the outpatient setting. Many potential and actual safety problems occur there as well.(1) Yet patient safety literature and practice do not seem to have reached deeply into ambulatory care. This is likely due to a combination of factors: in most practices, there is no layer of administration providing a second look at routine policies and procedures; there is no accrediting agency, like The Joint Commission, to mandate safe practices (2); and those of us in office practice are so consumed with simply getting through the day that it is difficult to recognize the problems, large and small, that can lead to major safety hazards. The business case for safety, such as it is, relies almost entirely on the malpractice rate-setting process: errors that result in litigation lead to higher premiums and personal and professional misery. However, as Studdert (3) has argued, relying on the malpractice system to identify and "correct" errors is unlikely to be timely or productive.
Journal Article > Commentary
Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.
Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.
This article discusses hospital compliance with National Patient Safety Goals regarding medication safety and describes strategies to improve anticoagulant administration safety.
Journal Article > Study
Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out?
Suba EJ, Pfeifer JD, Raab SS. J Urol. 2007;178:1245-1248.
This study summarizes the findings from three root cause analyses to highlight the challenges in preventing patient identification errors in surgical pathology specimens. The authors suggest the use of a time-out strategy that would reduce the risk of the wrong patient receiving radiation or surgical therapy.
Journal Article > Commentary
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2007;42:181–182.
This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values.