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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 1
- Quality Improvement Strategies 2
Search results for "Monitoring Errors and Failures"
- Error Analysis
- Monitoring Errors and Failures
Journal Article > Study
Hurley JS, Roberts M, Solberg LI, et al. J Gen Intern Med. 2005;20:331-333.
This AHRQ–funded study retrospectively examined the failure rate of recommended laboratory surveillance for patients on specific chronic medications. Using claims data from two large health plans, the investigators selected 11 drugs and their recommended lab testing intervals to capture and analyze data. Results suggested that nearly half of those requiring a chronic medication were subject to a potential laboratory monitoring error per year. Discussion includes detailed presentation of the potential error rates and how they differed among specific drugs and lab tests. The authors conclude that the prevalence of inadequate laboratory monitoring should stimulate further research about its impact on several clinical outcomes.
Cases & Commentaries
- Spotlight Case
- Web M&M
Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD; July 2006
An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
Journal Article > Study
Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. Anesthesiology. 2006;104:228-234.
Using closed malpractice claims from a previously described database, this study discovered significant patient injury associated with monitored anesthesia care (MAC) and a liability profile similar to that of general anesthesia. Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of general and regional anesthesia, and report on the claim characteristics. MAC claims involved older and more ill patients, with respiratory depression being the most frequent occurrence leading to patient injuries. The authors conclude that more than half of the claims would be preventable with improved monitoring strategies.
Journal Article > Commentary
Kovner C, Menezes J, Goldberg JD. Jt Comm J Qual Patient Saf. 2005;31:379-385.
In this AHRQ-funded study, the investigators reviewed the medication management process for home care and developed several recommendations to improve safety.