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Search results for "Active Errors"

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Journal Article > Study

Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit.

Solanki R, Mondal N, Mahalakshmy T, Bhat V. Arch Dis Child. 2017 May 3; [Epub ahead of print].

Pediatric patients are at high risk for medication errors. Researchers conducted a cross-sectional study on 166 infants younger than 3 months who were discharged from the hospital. They found a high frequency of medication errors by caregivers. In keeping with prior research, dose administration errors were the most common type of error.

Journal Article > Commentary

Two fatal cases of accidental intrathecal vincristine administration: learning from death events.

Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Chemotherapy. 2015;61:108-110.

Incorrectly administered vincristine can lead to serious adverse consequences. Discussing two incidents involving accidental intrathecal vincristine administration, this commentary describes how the health care organization implemented changes (including using different bags for drugs and label colors for syringes) following the first event and made further revisions when the second incident occurred 7 years later (such as ensuring drugs are delivered during different times and in certain settings).

Journal Article > Study

Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients.

Hsu CC, Chou CY, Chou CL, et al. PLoS One. 2014;9:e114359.

Clinicians may prescribe split pills for many different reasons, including dosing flexibility and patient affordability; however, this practice presents potential hazards. Splitting medications that are formulated to be extended-release or enteric-coated can lead to possibly dangerous changes in the drug's functionality. This study discusses the introduction of a clinical decision support warning that created a "hard stop" for any time an outpatient clinician attempted to prescribe a split pill for these special formulation medications. The study site was an academic medical center in Taiwan that performs more than 2.5 million ambulatory visits per year. The intervention resulted in a sharp decline in inappropriate medication splitting from a rate of approximately 0.61% to below 0.2%, where it has remained for at least 10 consecutive months. The use of a hard stop order can be controversial, as this method has resulted in unintended consequences in the past. A prior AHRQ WebM&M perspective discussed some of the tensions related to implementing medication decision support systems.

Journal Article > Study

Application of failure mode effect analysis to improve the care of septic patients admitted through the emergency department.

Alamry A, Al Owais SM, Marini AM, Al-Dorzi H, Alsolamy S, Arabi Y. J Patient Saf. 2017;13:76-81.

A multidisciplinary team employed failure mode and effect analysis methodology to detect potential problems in the process of treating patients with sepsis at a large academic medical center in Saudi Arabia. The authors identified a set of corrective actions that they intend to implement to improve patient care.

Journal Article > Study

Parental involvement in the preoperative surgical safety checklist is welcomed by both parents and staff.

Corbally MT, Tierney E. Int J Pediatr. 2014;2014:791490.

Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.

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 > Study

(How) do we learn from errors? A prospective study of the link between the ward's learning practices and medication administration errors.

Drach-Zahavy A, Somech A, Admi H, Peterfreund I, Peker H, Priente O. Int J Nurs Stud. 2014;51:448-457.

Supervisory learning, in which senior nurses monitored and provided feedback for junior nurses, was associated with a lower risk of medication administration errors in this Israeli study.

Journal Article > Study

Accuracies of diagnostic methods for acute appendicitis.

Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Am Surg. 2013;79:101-106.

Comparison of diagnostic methods for acute appendicitis found that a strategy relying on ultrasonography as the initial diagnostic test would minimize diagnostic errors.

Journal Article > Study

Surgeon commitment to trauma care decreases missed injuries.

Lin YK, Lin CJ, Chan HM, et al. Injury. 2014;45:83-87.

Full-time trauma surgeons had a lower incidence of diagnostic errors (defined as the incidence of missed injuries in severely injured patients) compared with surgeons who primarily practiced in other specialties, according to this retrospective analysis of patients admitted to a Taiwanese surgical intensive care unit.

Journal Article > Study

Medical error disclosure: the gap between attitude and practice.

Ghalandarpoorattar SM, Kaviani A, Asghari F. Postgrad Med J. 2012;88:130-133.

Attending surgeons and surgical residents in Iran cited concerns about malpractice litigation and fear of losing patients' trust as reasons why they did not disclose errors to patients.

Journal Article > Study

Fractures of the fingers missed or misdiagnosed on poorly positioned or poorly taken radiographs: a retrospective study.

Tuncer S, Aksu N, Dilek H, Ozkan T, Hamzaoglu A. J Trauma. 2011;71:649-655.

Technically inadequate radiographs were responsible for a significant number of missed diagnoses of finger fractures after hand trauma. The authors of this retrospective study propose recommendations to avert this problem.

Journal Article > Study

Medication prescribing errors in the prehospital setting and in the ED.

Lifshitz AE, Goldstein LH, Sharist M, et al. Am J Emerg Med. 2012;30:726-731.

This study discovered that medication errors were more common in the emergency department setting than in emergency vehicles, and patients requiring multiple medications were at higher risk for medication errors.

Journal Article > Study

Assessing the accuracy of drug profiles in an electronic medical record system of a Washington State hospital.

Platte B, Akinci F, Güç Y. Am J Manag Care. 2010;16:e245-e250.

The accuracy of medication profiles at a small hospital was superior to that documented in other studies, a finding which the authors attribute to use of an integrated medication reconciliation system within the electronic medical record.

Journal Article > Study

Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice.

Pakis I, Polat O, Yayci N, Karapirli M. Am J Forensic Med Pathol. 2010;31:218-221.

This study from Turkey confirms the utility of autopsies in identifying diagnostic errors, as there was discordance between the clinical and pathologic diagnoses in 13.8% of cases.

Journal Article > Study

Cognitive error as the most frequent contributory factor in cases of medical injury: a study on verdict's judgment among closed claims in Japan.

Tokuda Y, Kishida N, Konishi R, Koizumi S. J Hosp Med. 2011;6:109-114.

This closed claims analysis found that cognitive factors, including errors in judgment and failure of vigilance, were important and frequent causes of medical injury.

Journal Article > Commentary

The hazards of diagnosis.

Schattner A, Magazanik N, Haran M. QJM. 2010;103:583-587.

This commentary discusses factors that contribute to diagnostic errors along with steps physicians should take to ensure patient-centered diagnostic communication.

Journal Article > Study

The value of 'gentle reminder' on safe medical behaviour.

Erev I, Rodensky D, Levi MA, Englard-Hershler M, Admi H, Donchin Y. Qual Saf Health Care. 2010;19:e49.

Peer feedback was effective at reducing unsafe behaviors of physicians and staff in this Israeli study.

Journal Article > Study

Revisiting old slides—how worthwhile is it?

Agarwal S, Wadhwa N. Pathol Res Pract. 2010;206:368-371.

This study reviewed more than 2400 surgical pathology cases and found major diagnostic discrepancies in nearly 7% of cases. The authors advocate for such review to provide opportunities for learning and improvement.

Journal Article > Study

Potential medical adverse events associated with death: a forensic pathology perspective.

Sakai K, Takatsu A, Shigeta A, et al. Int J Qual Health Care. 2010;22:9-15.

Nearly 9% of autopsies in this Japanese study revealed a potentially preventable adverse event, most commonly a diagnostic error.

Journal Article > Study

Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety.

Porat N, Bitan Y, Shefi D, Donchin Y, Rozenbaum H. Qual Saf Health Care. 2009;18:505-509.

Specific labels for high-risk intravenous medications successfully reduced medication errors and allowed nurses to identify medications more efficiently.

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