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Search results for "Error Analysis"
Singh H. National Quality Measures Expert Commentaries. November 23, 2015.
Recently, diagnostic error has garnered much discussion and examination, but further research is needed to understand and track such errors. This article reviews evidence on the topic to illustrate measurement challenges and includes a sociotechnical model to identify, assess, and address diagnostic errors.
Wallace SC. PA-PSRS Patient Saf Advis. 2015;12:62-70.
This article analyzed data on dietary errors submitted to a state reporting program and found that more than 60% of patients received trays containing food items to which they were allergic. Recommendations to prevent such errors include standardizing practices and using whiteboards as communication tools.
Wachter RM. National Quality Measures Clearinghouse: Expert Commentaries; March 3, 2008.
This commentary describes how the focus on measurement in health care has affected both quality and safety initiatives.
Grissinger M. PA-PSRS Patient Saf Advis. December 2016;13:137-148.
Drawing from reports of medication errors submitted over a 7-year period to the Pennsylvania Patient Safety Authority, this analysis found that common problems included drug incompatibility and drug–drug interaction. The article cautions against relying on drug ordering alerts as the sole strategy for preventing potentially harmful prescribing.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
Herzer K, Seshamani M. HealthReform.Gov. July 2009.
PA-PSRS Patient Saf Advis. May 2007;4(suppl 2):1-8.
This article shares findings from a workgroup that assessed the efficacy of pharmacy computer systems in detecting unsafe medication orders. The 30 Pennsylvania hospitals that participated in the workgroup found that their systems were not catching all unsafe orders.