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Search results for "Active Errors"

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Journal Article > Study

Overdose risk in young children of women prescribed opioids.

Finkelstein Y, Macdonald EM, Gonzalez A, Sivilotti MLA, Mamdani MM, Juurlink DN; Canadian Drug Safety And Effectiveness Research Network (CDSERN). Pediatrics. 2017;139:e20162887.

Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.

Journal Article > Study

All consumer medication information is not created equal: implications for medication safety.

Monkman H, Kushniruk AW. Stud Health Technol Inform. 2017;234:233-237.

Medication management in outpatient settings requires patients to recognize adverse medication effects. This expert review study found that standardized information from a large Canadian retail pharmacy lacked key information about possible adverse effects and drug interactions. The authors suggest that this information gap leads to an urgent and addressable patient safety risk.

Journal Article > Study

Reevaluation of diagnosis in adults with physician-diagnosed asthma.

Aaron SD, Vandemheen KL, FitzGerald JM, et al; Canadian Respiratory Research Network. JAMA. 2017;317:269-279.

Misdiagnosis can contribute to overuse of unnecessary medication and treatments as well as a delay in appropriate treatment, placing patients at increased risk of harm. This prospective cohort study suggests that asthma may be frequently misdiagnosed in the community setting as a result of inadequate testing for airflow limitations. In 2% of the cases analyzed, a serious underlying cardiorespiratory condition was misdiagnosed as asthma.

Book/Report

Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.

Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.

Use of medication administration technologies can reduce transcription errors. This review examined computerized order entry systems, barcode medication administration systems, and other tools that can prevent medication transcription errors.

Journal Article > Commentary

Estimating deaths due to medical error: the ongoing controversy and why it matters.

Shojania KG, Dixon-Woods M. BMJ Qual Saf. 2017;26:423-428.

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.

Journal Article > Commentary

JAMA professionalism: disclosure of medical error.

  • Classic

Levinson W, Yeung J, Ginsburg S. JAMA. 2016;316:764-765.

Disclosing medical errors to patients is essential for maintaining a therapeutic relationship and preventing further harm. This commentary describes a case in which a physician inadvertently used nonsterile instruments to perform procedures on two patients and presents options for what the physician might do next. Recommended best practices for error disclosure include being honest about what happened, explicitly stating that an error occurred, and explaining to the patient any relevant specific information that might be helpful in terms of necessary follow-up. The authors suggest that all errors be formally reviewed to prevent future harm and that health care systems should create an environment that facilitates error reporting.

Journal Article > Study

A framework to assess patient-reported adverse outcomes arising during hospitalization.

Barbara O, Jose SM, Jayna HL, et al. BMC Health Serv Res. 2016;16:357.

Patient reports of adverse outcomes are one critical method to detect safety hazards. This study used patient reports of adverse outcomes to develop a framework for identifying adverse events. The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for adverse events.

Journal Article > Review

Adverse drug event reporting systems: a systematic review.

Bailey C, Peddie D, Wickham ME, et al. Br J Clin Pharmacol. 2016;82:17-29.

Adverse drug events (ADEs) remain one of the most common types of inpatient errors, affecting almost 5% of hospitalized patients, and lead to hundreds of thousands of emergency department visits and hospitalizations every year. Reporting ADEs is a crucial aspect of drug safety monitoring programs and international reporting standards are lacking. This study analyzed 108 ADE reporting systems and found significant variability in the data fields used to collect information. The authors suggest that standardization of data collection might improve drug safety monitoring by facilitating data aggregation on a larger scale.

Journal Article > Study

The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors.

Sears K, O'Brien-Pallas L, Stevens B, Murphy GT. J Pediatr Nurs. 2016;31:e283-e290.

This Canadian study found that nurses with more experience reported a greater number of pediatric medication administration errors, but these errors were less severe compared to other units. This finding suggests widespread underreporting of medication errors by nurses with a lower level of experience.

Newspaper/Magazine Article

Selection of incorrect medication pump leads to chemotherapy overdose.

ISMP Canada. August 26, 2015;15:1-4.

Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. In response to an incident involving a chemotherapy administration error as a result of utilizing the incorrect infusion pump, this newsletter article discusses the development of a point-of-care checklist to assist in use of infusion pumps to improve safety.

Journal Article > Study

How surgical trainees handle catastrophic errors: a qualitative study.

Balogun JA, Bramall AN, Bernstein M. J Surg Educ. 2015;72:1179-1184.

According to this qualitative study, surgery resident physicians perceive that catastrophic errors result from system problems and provide lessons for future practice. Participants did not feel comfortable discussing errors with staff and reported work culture as a barrier to asking for support, demonstrating the need to teach trainees about error disclosure.

Newspaper/Magazine Article

Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.'

Blackwell T. National Post. January 16, 2015.

Reporting on the lack of transparency around medical errors in Canada, this news article relates how errors are being repeated across the country due to the systemic failure to have open discussions about adverse events.

Journal Article > Commentary

Educational opportunities with postevent debriefing.

Mullan PC, Kessler DO, Cheng A. JAMA. 2014;312:2333-2334.

Real-time or near real-time learning opportunities can drive improvement in health care. This commentary explains why debriefings after clinical events are a valuable educational strategy and provides insights into how clinical teams can implement debrief initiatives.

Newspaper/Magazine Article

Reminder: pay attention to the appearance of your medicines.

ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.

This newsletter article describes an incident involving a patient who noticed that the tablets in her prescription refill had a different marking than usual, alerting her that she might have received an incorrect medication which was confirmed by the pharmacist. Tips for patients to avoid medication errors include being familiar with how their medicines look and checking prescriptions before leaving the pharmacy. Practitioners can help prevent these errors by counting and labeling prescriptions one at a time and performing patient consultations.

Journal Article > Study

Pediatric crisis resource management training improves emergency medicine trainees' perceived ability to manage emergencies and ability to identify teamwork errors.

Bank I, Snell L, Bhanji F. Pediatr Emerg Care. 2014;30:879-883.

Emergency medicine residents receive variable exposure to pediatric resuscitation situations during their training, highlighting the need for effective simulation–based education. In this study, a crew resource management–based teamwork training workshop increased emergency medicine residents' knowledge of teamwork concepts and enhanced their ability to detect errors.

Journal Article > Study

Blink or think: can further reflection improve initial diagnostic impressions?

Hess BJ, Lipner RS, Thompson V, Holmboe ES, Graber ML. Acad Med. 2015;90:112-118.

This direct observation study examined cognition among experienced clinicians in the setting of their recertification examination and found that when they changed answers, it was usually from an incorrect to a correct response. This suggests that further reflection enhances accuracy compared to intuitive response, consistent with work on metacognition to enhance diagnostic accuracy.

Newspaper/Magazine Article

Hamilton father misdiagnosed with lung cancer demands answers.

Carville O. The Star. November 14, 2014.

This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and touches on the psychological impact of diagnostic error on the patient and his family. The potential causes of the mistake include laboratory sample confusion and misinterpretation of biopsy results.

Journal Article > Study

Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.

Greenall J, Shastay A, Vaida AJ, et al. J Oncol Pharm Pract. 2015;21:26-35.

In 2012, more than 350 organizations from 13 countries participated in the initial Institute for Safe Medication Practices self-assessment for oncology. This study describes results from this baseline survey, which revealed key opportunities for improvements in the safe delivery of chemotherapy. For example, many institutions have still not followed best practices for the administration of vincristine. In addition, less than half of respondents had fully implemented safety processes for oral chemotherapy orders. A prior AHRQ WebM&M commentary describes a patient who inadvertently received the wrong chemotherapy regimen and explores the high risks associated with inpatient chemotherapy.

Journal Article > Review

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use.

Kukreti V, Cosby R, Cheung A, Lankshear S; ST Computerized Prescriber Order Entry Guideline Development Group. Curr Oncol. 2014;21:e604-e612.

Medication error rates are extremely high among patients receiving outpatient chemotherapy. This systematic review found a paucity of studies on the effectiveness of computerized provider order entry (CPOE) in improving the safety of chemotherapy, but concluded that the limited evidence supports wider use of CPOE in this setting.

Journal Article > Commentary

Is it time to move beyond errors in clinical reasoning and discuss accuracy?

Wood TJ. Adv Health Sci Educ Theory Pract. 2014;19:403-407.

Highlighting how heuristics can both increase and reduce risk of diagnostic error, this commentary applies a set of recommended criteria to examine its usefulness in guiding research and augmenting understanding about factors that affect clinical reasoning and support accurate decision making.

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