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Search results for "Active Errors"

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Newspaper/Magazine Article

Is your patient ready to go home?

Hoenig LJ. Med Econ. 2006 Jun 2;83:45-46.

The author discusses the importance of thorough discharge examinations.

Journal Article > Study

Operational failures and interruptions in hospital nursing.

Tucker AL, Spear SJ. Health Serv Res. 2006;41:643-662.

This study discovered that nurses experienced more than eight work system failures during an 8-hour shift. Investigators combined primary observation with interview and survey methods to understand the role work system failures play on nurse effectiveness. The most frequent failures identified involved medications, orders, supplies, staffing, and equipment. In addition to operational failures that delayed productivity, a large number of reported work interruptions contributed to the study findings. The authors advocate for continued efforts to differentiate between tactics taken by bedside nurses to prevent error with tactics that result from the system (eg, interruptions), which often put patients at risk for error.

Journal Article > Commentary

The Sorry Works! Coalition: making the case for full disclosure.

Wojcieszak D, Banja J, Houk C. Jt Comm J Qual Patient Saf. 2006;32:344-350.

The authors describe the work of The Sorry Works! Coalition, which aims to minimize the stress and cost associated with medical error by promoting full disclosure and apology.

Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

This monthly selection of medication error reports discusses a mistake with chelation therapy agents due to similar acronym use, confusion of drugs similarly named in different countries, and inadequate information about changes to an existing drug.

Special or Theme Issue

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.

Meeting/Conference > Kansas Meeting/Conference

Second Victim Train-the-Trainer Workshop.

Center for Patient Safety and University of Missouri. November 10, 2017; Saint Luke's North Hospital, Barry Road, Kansas City, MO.

Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies to build an organizational program that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.

Meeting/Conference > Massachusetts Meeting/Conference

Improving Patient Safety With Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 26–27, 2017; Constellation Energy Building, Baltimore, MD.

This two-day workshop will discuss of how human factors engineering methods can be applied to identify risks, augment the work environment, and evaluate technology to address potential system failures in health care. 

Meeting/Conference > Massachusetts Meeting/Conference

Patient Safety and Healthcare Quality Improvement 2017.

Harvard Medical School. October 16-17, 2017; Sheraton Boston Hotel, Boston, MA.

This workshop offers insights from safety leaders about applying strategies and guidelines to quality and safety improvement in the acute care setting. This conference has expanded its scope beyond clinicians and patient safety officers to provide educational resources for pharmacists and nurses. Keynote speakers include James Conway and Dr. Thomas H. Lee.

Meeting/Conference > Oregon Meeting/Conference

Speak Up for Patient Safety: Communicating Before, During and After an Adverse Event.

Oregon Patient Safety Commission. August 11, 2017; OMEF Event Center, Portland, OR.

Effective communication among clinical teams and with patients and families is a key component of safe patient care. This workshop will discuss strategies to enhance communication among staff and patients, including concepts from TeamSTEPPS and how to foster a culture that promotes identifying areas for improvement and remaining transparent during an incident.

Meeting/Conference > District of Columbia Meeting/Conference

Improving Diagnosis in Health Care: An Implementation Workshop.

The National Academies of Sciences, Engineering, and Medicine. July 17, 2017; National Academy of Sciences Building, Washington, DC.

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report in 2015. This workshop will discuss progress since the report's release and review strategies for building on those successes to reduce diagnostic error.

Newspaper/Magazine Article

Death due to pharmacy compounding error reinforces need for safety focus.

ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.

Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.

Newspaper/Magazine Article

Rude providers jeopardize patient safety. So stop it.

Thew J. HealthLeaders Media. June 14, 2017.

Rudeness can affect teamwork and hinder safe, transparent care. This news article reports on one hospital's approach to manage disruptive behavior through strategies such as peer identification and proactive behavior adjustment.

Journal Article > Commentary

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Journal Article > Commentary

Implementation of a modified bedside handoff for a postpartum unit.

Wollenhaup CA, Stevenson EL, Thompson J, Gordon HA, Nunn G. J Nurs Adm. 2017;47:320-326.

Ineffective team communication can contribute to sentinel events. This commentary describes how a rural hospital's postpartum unit redesigned its handoff process to create a bedside handoff model and utilized structured educational modalities and nurse champions to drive improvement and acceptance of the approach.

Journal Article > Study

Proactive risk assessment of surgical site infections in ambulatory surgery centers.

Bish EK, Azadeh-Fard N, Steighner LA, Hall KK, Slonim AD. J Patient Saf. 2017;13:69-75.

This study reports on the use of a prospective risk assessment tool to identify risks for surgical site infection in an ambulatory surgery center. A safety intervention was developed that specifically targeted the vulnerabilities identified by the risk assessment. Other methods of prospective error detection are discussed in the Detection of Safety Hazards Patient Safety Primer.

Journal Article > Study

Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.

Sparks JL, Crouch DL, Sobba K, et al. JAMA Surg. 2017 May 24; [Epub ahead of print].

Multiple studies have linked poor teamwork and communication to adverse events in the operating room. There is a growing recognition that surgeons must learn these nontechnical skills during training in addition to the traditional focus on technical ability. In this controlled study, surgical residents participated in an educational intervention (a simulated surgical emergency) that simultaneously targeted technical and nontechnical skill development. The study used two different types of simulation—high fidelity (a cadaver) and medium fidelity (an anatomically correct mannequin)—compared to a control group, which used a nonanatomic simulator. Investigators found that nontechnical skills improved in both intervention groups compared to the control group, measured using validated teamwork assessments. As the accompanying editorial notes, the study findings indicate that technical and nontechnical skills may be best taught together, as teamwork skills improved when residents also had to perform a simulated surgical task simultaneously.

Journal Article > Commentary

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review.

Henriksen K, Dymek C, Harrison MI, Brady JP, Arnold SB. Diagnosis. 2017 May 23; [Epub ahead of print].

Diagnostic error gained recognition as a patient safety concern with the publication of the Improving Diagnosis in Health Care report. This commentary reviews insights shared at a conference convened to discuss issues associated with diagnosis, including the need for concrete definitions of diagnostic error, the role of technology in improvement, and organizational factors that contribute to the problem.

Journal Article > Study

A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents.

Mody L, Greene MT, Meddings J, et al. JAMA Intern Med. 2017 May 19; [Epub ahead of print].

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

Newspaper/Magazine Article

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.

Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.

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