Search results for "Active Errors"

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Weight-based medication dosing can lead to medication errors in pediatric patients. Investigators used a trigger tool to detect weight-entry errors in the electronic health record. They found that dosing errors are rare and are most likely to occur in urgent and emergent settings. These findings suggest that a weight-entry trigger tool can identify pediatric patients at risk for dosing errors.

A recent article asserted that medical error is the third leading cause of death in the United States. This perspective questions the accuracy of this estimate. The authors note that this estimate was generated by simply combining medical error rates from prior studies, without adhering to guidelines for quantitative synthesis or accounting statistically for the uncertainty associated with the extrapolation of these studies. There are also inherent limitations in the original data, which used trigger tools to identify adverse events. The studies from which the error rates were calculated could not clearly determine whether the adverse events detected actually contributed to the patient's death. Patients who are critically ill tend to have more adverse events because they experience more medical interventions. However, their deaths may be due to the underlying illness rather than the medical care they received. The authors argue that an inaccurately high estimate for medical error–related mortality draws attention away from other crucial patient harms, such as pressure ulcers and medication safety, both of which rarely contribute to mortality but are of high priority to patients.

Insufficient follow-up of test results is a known contributor to missed and delayed diagnosis. This observational study used a trigger tool to detect diagnostic delays related to chest imaging follow-up. Investigators used an automated algorithm to identify chest imaging cases that potentially had a follow-up delay. A clinician then reviewed the medical records for a random sample of cases identified by the trigger tool and a reference set of cases involving patients with abnormal test results but no delays. They found that the trigger tool had 99% sensitivity and 38% specificity in detecting delays in follow-up of abnormal chest imaging. The authors suggest that this trigger tool may help identify patients at risk for diagnostic delay following abnormal chest imaging. A WebM&M commentary discussed delayed follow-up of a diagnostic test.

A woman who had recently had her left lung removed for aspergilloma presented to the outpatient clinic with pain, redness, and pus draining from her sternotomy site. She was admitted for surgical debridement and prescribed IV liposomal amphotericin B for aspergillus. Hours into the IV infusion, the patient developed nausea, vomiting, sweating, and shivering, and it was discovered that she had been given conventional amphotericin B at the dose intended for the liposomal formulation, representing a 5-fold overdose.

Delays in follow-up of abnormal test results are known to contribute to delayed and missed diagnosis. Investigators developed and validated an electronic trigger to identify potential delays in follow-up of abnormal chest computed tomography scans. This study found that more than half of the flagged cases had a true diagnostic delay. This work should lead to prospective evaluation of trigger approaches to enhance test result follow-up.

This commentary describes the development of a trigger tool initiative to detect and record adverse events in pediatric anesthesiology. The process included identifying which medications to track, creating a search mechanism, implementing the tool, and disseminating the data.

This focus group study examined leadership, clinician, and administrator perspectives on implementation of an adverse event surveillance system. A trained clinical observer assessed triggers designed to indicate a possible adverse event in general medicine inpatient ward settings. Participants supported the approach and involvement of frontline staff in safety surveillance to foster a safety culture and enhance patient safety education for trainees.

This commentary discusses the use of triggers in electronic health records to identify potential diagnostic errors.

The Institute for Healthcare Improvement's Global Trigger Tool has been used to quantify the incidence of preventable harm in seminal studies. This study describes how a large health system used the Global Trigger Tool to identify causes of preventable harm, track adverse event rates over time, and guide improvement efforts. Through a standardized assessment and dissemination process, this health system achieved reductions in preventable adverse events across its 25 hospitals over a 2-year period. Although the Global Trigger Tool is widely used, concerns have been raised about its reliability, and it is generally recommended that organizations should use multiple methods of detecting safety hazards to gain a comprehensive picture of patient safety.

This commentary describes an incident involving an inappropriate override of a drug allergy alert and details changes the hospital made in its medication allergy alert system in response to the event.

Adverse events after hospital discharge are a continued threat to patient safety and the basis for interventions targeting key contributing factors. Premature discharge is an area less studied, partly because the decision-making for safe discharge falls on individual providers and their clinical assessment. This study developed a set of triggers based on selected laboratory abnormalities that could systematically identify patients potentially unsafe for discharge. Triggers that led to a discharge alert included an elevated white blood cell count, a rising creatinine level, specific abnormalities in electrolytes, and an elevated international normalized ratio (INR) in the absence of anticoagulant therapy. The discharge filter tool requires further validation, but it represents an innovation that leverages computerized systems to provide safer care.

The impact of clinical decision support systems on improving medication safety has been limited by a lack of standardized and tailored alerts to warn prescribing clinicians about dangerous drug–drug interactions. Progress in this area has stalled owing to disagreement between clinicians and system designers along with concerns about liability if warnings are deployed incorrectly. This study reports on the development of a consensus list of 15 high-severity, clinically significant drug–drug interactions, arrived at through an expert panel approach that included input from pharmacists, physicians, electronic medical record (EMR) developers, and developers of online clinical knowledge bases. The authors recommend that alerts to prevent these interactions should be implemented in all EMRs.

Diagnostic errors are one of the most common types of preventable errors in ambulatory care, according to data from closed malpractice claims. Difficulty in identifying missed and delayed diagnoses has hampered progress in addressing diagnostic errors. In this case-control study, investigators assessed two triggers for identifying possible cases of diagnostic error within an electronic health record. These triggers were refined from a prior study by the same investigators. The trigger methodology was reasonably accurate in identifying likely diagnostic errors, although the study was limited by poor interrater reliability between physician reviewers on whether an error occurred. Nevertheless, this study demonstrates the potential of screening approaches within electronic medical records for identifying and categorizing possible diagnostic errors.

Drug administration errors are a major safety concern in anesthesiology, as even routine cases can require administration of several high-risk medications. In this randomized controlled trial, a novel system for drug administration was evaluated in comparison with usual anesthesia practice. The new system was designed according to human factors engineering principles and included proven safety measures such as barcode medication administration. Although fewer overall errors occurred with the new system, the reduction in administration errors occurred only when barcoding was performed consistently and safety alerts were heeded. The anesthesia field has long been a leader in patient safety, and in fact, some of the earliest studies in the patient safety field evaluated the role of human factors in anesthesia medication administration errors.

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.

This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.

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.

This study found that computerized surveillance systems detected more hospital-acquired infections than manual chart review, but both methods detected similar rates of adverse drug events. The authors discuss the tradeoffs of each surveillance method and highlight how each system used information from different sources.

This newspaper article reports on an order entry error that resulted in a 60-fold overdose and raised concerns about the safety of electronic medication data systems.