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Search results for "Active Errors"

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Journal Article > Study

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study.

Gilmartin-Thomas JF, Smith F, Wolfe R, Jani Y. Int J Nurs Stud. 2017;72:15-23.

This prospective, direct-observation study examined medication administration accuracy of medications dispensed by nurses and caregivers in long-term care facilities. Investigators compared medication administration from original medication packaging to administration from multicompartment medication devices. The team observed nearly 2500 doses. When medications were dispensed from original packaging, the medication administration error rate was 9%. When multicompartment devices were used, the medication administration error rate was 3%. This difference persisted in settings where both original packaging and multicompartment medication devices were used. This study adds to the evidence about how literacy-friendly health systems can enhance medication safety.

Journal Article > Study

Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study.

Prakash S, Bihari S, Need P, Sprick C, Schuwirth L. BMC Med Educ. 2017;17:36.

Cognitive bias can lead to diagnostic error. To better understand the prevalence of cognitive error among first-year residents, interns were observed as they handled acute clinical problems during simulation sessions. Researchers found a high prevalence of cognitive error, which did not change over time and adversely affected clinical performance.

Journal Article > Review

Managing the patient identification crisis in healthcare and laboratory medicine.

Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Clin Biochem. 2017;50:562-567.

Patient identification mistakes associated with diagnostic blood testing can have serious consequences. This commentary recommends several strategies to redesign laboratory processes to reduce risks of specimen misidentification, such as utilizing at least two patient identifiers, providing staff training, and using technologies to track and manage specimens.

Journal Article > Review

Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents.

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Ferrah N, Lovell JJ, Ibrahim JE. J Am Geriatr Soc. 2017;65:433-442.

Older adults living in long-term care facilities face significant safety hazards. This systematic review examined medication errors in nursing homes and found a high prevalence of errors overall. The review revealed that a significant number of errors were related to handoffs and that 75% of these older patients received at least one potentially inappropriate medication. However, serious harm associated with medication use was reported for less than 1% of errors. The authors emphasize the difficulty of attributing harm to medications versus underlying illness in nursing home residents, and they call for designing safer systems for medication administration in nursing homes. A previous WebM&M commentary discussed challenges to ensuring patient safety in long-term care facilities.

Journal Article > Study

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

Jones A, Johnstone MJ. Aust Crit Care. 2017;30:219-223.

This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.

Journal Article > Commentary

Case report of a medication error: in the eye of the beholder.

Naunton M, Nor K, Bartholomaeus A, Thomas J, Kosari S. Medicine (Baltimore). 2016;95:e4186.

Look-alike drug names or packaging are known to contribute to medication errors. This case discussion reviews an error in the community setting involving a nonocular medication mistakenly administered as an eye drop due to look-alike packaging and recommends ways to improve storage and disposal processes to avoid similar incidents.

Journal Article > Commentary

Recommended responsibilities for management of MR safety.

Calamante F, Ittermann B, Kanal E, Norris D; Inter-Society Working Group on MR Safety. J Magn Reson Imaging. 2016;44:1067-1106.

Magnetic resonance safety events can lead to serious patient harm. This commentary provides recommendations from expert consensus to help organizations design and implement a range of magnetic resonance imaging services. The authors also define three levels of management responsibilities required to support those recommendations in a various settings.

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 > Commentary

'Just culture': improving safety by achieving substantive, procedural and restorative justice.

Dekker SWA, Breakey H. Saf Sci. 2016;85:187-193.

A just culture balances organizational context with appropriate accountability after an error. This commentary outlines moral and safety issues that just culture approaches should address to build trust for blame-free response to error and enable learning from failure.

Journal Article > Commentary

Threats to safety during sedation outside of the operating room and the death of Michael Jackson.

Webster CS, Mason KP, Shafer SL. Curr Opin Anaesthesiol. 2016;29(suppl 1):S36-S47.

As use of anesthesia outside the operating room increases, the hazards associated with the practice are becoming more evident. This review discusses sedation in the ambulatory setting and highlights how factors related to the care environment, equipment, and teamwork contribute to the risks.

Journal Article > Commentary

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.

Graudins LV, Downey G, Bui T, Dooley MJ. Jt Comm J Qual Patient Saf. 2016;42:86-95.

Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.

Journal Article > Study

Data quality associated with handwritten laboratory test requests: classification and frequency of data-entry errors for outpatient serology tests.

Vecellio E, Maley MW, Toouli G, Georgiou A, Westbrook J. HIM J. 2015;44:7-12.

This audit of handwritten laboratory orders transcribed into electronic information systems found a 10% error rate, most of which were associated with transcription, a known safety vulnerability. These results underscore the benefit of computerized physician order entry for patient safety.

Journal Article > Review

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

Hayes C, Jackson D, Davidson PM, Power T. J Clin Nurs. 2015;24:3063-3076.

This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.

Journal Article > Study

Apologies following an adverse medical event: the importance of focusing on the consumer's needs.

Allan A, McKillop D, Dooley J, Allan MM, Preece DA. Patient Educ Couns. 2015;98:1058-1062.

In this study, participants observed two video-recorded scenarios of a surgeon apologizing for an adverse event. Although apologies that focused on admissions of responsibility, expressions of regret, and offers of restitution were viewed positively, those that also explicitly accounted for the patient's perspective by understanding the impact on the patient and offering to address the harm in a meaningful manner were better received.

Journal Article > Study

Safety incidents in the primary care office setting.

Rees P, Edwards A, Panesar S, et al. Pediatrics. 2015;135:1027-1035.

Patient safety in outpatient settings is a growing concern. In this analysis of voluntarily reported safety events from the United Kingdom, researchers identified serious risks for children cared for in outpatient family medicine settings. Medication management, diagnostic errors, and errors in the referral process contributed significantly to patient harm, echoing prior studies about outpatient safety. The authors call for implementation of safety practices such as barcode medication administration, clinical decision support software, and electronic referral tracking, all of which remain incompletely implemented in ambulatory care. Given the known under-reporting of adverse events, this report likely underestimates the frequency of patient safety problems in this outpatient setting and emphasizes the need for active safety monitoring.

Journal Article > Review

Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis.

Anderson K, Stowasser D, Freeman C, Scott I. BMJ Open. 2014;4:e006544.

This systematic review examined prescribing of potentially inappropriate medications and found that prescriber characteristics (such as clinical inertia and lack of knowledge) and system characteristics (such as insufficient time to review medications and limited availability of nonmedication treatments) both contributed to persistent prescribing of medications associated with increased risks. These findings emphasize the need for fundamental health care reform in order to improve medication safety.

Journal Article > Study

Doctors' experiences of adverse events in secondary care: the professional and personal impact.

Harrison R, Lawton R, Stewart K. Clin Med. 2014;14:585-590.

According to this survey study, physicians involved in adverse events experience personal and professional harm, and existing reporting practices are not helpful. These findings suggest that despite prior work, systems to address physician needs remain inadequate. Dr. Albert Wu discussed the second victim phenomenon in a past AHRQ WebM&M interview.

Journal Article > Commentary

Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners.

Bismark MM, Morris JM, Clarke C. Intern Med J. 2014;44:1165-1169.

Peers are likely to notice that a colleague is impaired before it is recognized at the system level, yet they are often reluctant to report it. Discussing the mandated reporting of impaired clinicians in the Australian health care system, this commentary suggests that efforts to improve reporting focus on identifying the root causes of impairment to provide mechanisms for colleagues that need support.

Journal Article > Commentary

A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy.

Boyd M. J Eval Clin Pract. 2015;21:461-469.

Although recommended as a patient safety improvement strategy, the value of root cause analysis has been debated. This commentary suggests a three-step approach for optimizing root cause analysis results to detect factors that contribute to adverse events. The author applies philosophical principles to identify and prioritize interventions to enhance benefit from root cause analysis.

Journal Article > Study

Error in intensive care: psychological repercussions and defense mechanisms among health professionals.

Laurent A, Aubert L, Chahraoui K, et al. Crit Care Med. 2014;42:2370-2378.

This interview study found that physicians and nurses experience guilt and shame following errors, echoing previous studies of the health care provider as the second victim in adverse events. A past AHRQ WebM&M interview with Dr. Albert Wu discusses the impact of errors on health care providers.

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