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Approach to Improving Safety
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Search results for "Central and South America"

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  • Central and South America
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Journal Article > Study

Evaluation of accuracy of IHI Trigger Tool in identifying adverse drug events: a prospective observational study.

das Dores Graciano Silva M, Martins MAP, de Gouvêa Viana L, et al. Br J Clin Pharmacol. 2018;84:2252-2259.

This study, conducted at a Brazilian hospital, found that the IHI Global Trigger Tool had relatively poor accuracy at identifying adverse drug events among hospitalized patients. The accuracy and reliability of trigger tools have been questioned in other studies.

Journal Article > Study

Diagnostic assessment of deep learning algorithms for detection of lymph node metastases in women with breast cancer.

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Ehteshami Bejnordi B, Veta M, Johannes van Diest P, et al; CAMELYON16 Consortium. JAMA. 2017;318:2199-2210.

Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.

Journal Article > Study

Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study.

Carlotti AP, Bachette LG, Carmona F, Manso PH, Vicente WV, Ramalho FS. Am J Clin Pathol. 2016;146:701-708.

This autopsy study demonstrated significant discrepancies between clinical and postmortem diagnoses among children who died in the intensive care unit. These results demonstrate the importance of autopsy as an educational tool for clinical teams to improve patient outcomes.

Journal Article > Review

Surgical count process for prevention of retained surgical items: an integrative review.

Freitas PS, Silveira RCCP, Clark AM, Galvão CM. J Clin Nurs. 2016;25:1835-1847.

Retained surgical items are considered a never event, but they continue to occur. Summarizing the evidence on surgical counts, this review explores risk factors, current processes, and technology solutions to determine best practices for perioperative nurses to prevent instances of retained surgical items.

Journal Article > Commentary

Positive deviance: a new tool for infection prevention and patient safety.

Marra AR, Pavão Dos Santos OF, Cendoroglo Neto M, Edmond MB. Curr Infect Dis Rep. 2013;15:544-548.

This commentary reveals how positive deviance can be applied in the hospital setting to reduce hospital-acquired infections.

Journal Article > Study

Delayed medical emergency team calls and associated outcomes.

Boniatti MM, Azzolini N, Viana MV, et al. Crit Care Med. 2014;42:26-30.

Rapid response teams have been widely implemented in hospitals, despite mixed evidence of their benefits. This prospective observational study demonstrated that delayed calls to the rapid response team were associated with higher 30-day mortality.

Journal Article > Study

Adverse drug events in a paediatric intensive care unit: a prospective cohort.

Silva DCB, Araujo OR, Arduini RG, Alonso CFR, Shibata ARO, Troster EJ. BMJ Open. 2013;3:ee001868.

This study used trigger tools to identify the incidence and risk factors for medication errors in a pediatric intensive care unit.

Journal Article > Study

Effects of the implementation of a preventive interventions program on the reduction of medication errors in critically ill adult patients.

Romero CM, Salazar N, Rojas L, et al. J Crit Care. 2013;28:451-460.

A multidisciplinary intervention significantly reduced the incidence of medication errors in an adult intensive care unit.

Journal Article > Commentary

Accident prevention in day-to-day clinical radiation therapy practice.

Baeza M. Ann ICRP. 2012;41:179-187.

Highlighting the prevalence and impact of errors in radiation therapy, this commentary recommends prevention tactics, including education and training on evolving technologies.

Journal Article > Study

Medication errors reported in a pediatric intensive care unit for oncologic patients.

Belela AS, Peterlini MA, Pedreira ML. Cancer Nurs. 2011;34:393-400.

This study found that omission and administration errors were the most common types of medication errors in a pediatric oncology population.

Journal Article > Study

Error in body weight estimation leads to inadequate parenteral anticoagulation.

Dos Reis Macedo LG, de Oliveira L, Pintão MC, Garcia AA, Pazin-Filho A. Am J Emerg Med. 2011;29:613-617.

Inadequate dosing of anticoagulant medications was common in the emergency department due to inaccurate estimation of body weight.

Meeting/Conference

Errors in Laboratory Medicine and Patient Safety.

Plebani M, ed. Clinica Chimica Acta. 2009;404(1):1-86.

This collection of papers presented at an international conference on laboratory medicine focuses on efforts to reduce medical errors in laboratory practice, especially those concerning diagnostic mistakes.

Journal Article > Study

Medication errors in an intensive care unit.

Bohomol E, Ramos LH,  D'Innocenzo M. J Adv Nurs. 2009;65:1259-1267. 

Pharmacy problems, including lack of medication availability and transcription problems, were the principal contributors to medication errors in this Brazilian study.

Journal Article > Study

Medication errors in pediatric inpatients: prevalence and results of a prevention program.

Otero P, Leyton A, Mariani G, Ceriani Cernadas JM; and Patient Safety Committee. Pediatrics. 2008;122:e737-e743.

This study examined medication error rates before and after implementation of interventions targeted toward an improved safety culture. Investigators demonstrated a modest but significant reduction in error prevalence.

Journal Article > Study

Clinical and pathological disagreement upon the cause of death in a teaching hospital: analysis of 100 autopsy cases in a prospective study.

Carvalho FLP, Cordeiro JA, Cury PM. Pathol Int. 2008;58:568-571.

This study discovered that autopsy-detected diagnostic errors occurred in 10% of cases examined, leading the authors to advocate for autopsy as an important learning strategy for clinicians. A past AHRQ WebM&M commentary discusses a case of a missed diagnosis that was discovered at autopsy.

Tools/Toolkit > Multi-use Website

Safe Surgery Saves Lives: The Second Global Patient Safety Challenge.

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Geneva, Switzerland: WHO World Alliance for Patient Safety; June 25, 2008.

This initiative provides a surgical safety checklist and related educational and training materials to encourage international adoption of a core set of safety standards. Implementation of this World Health Organization's checklist has resulted in dramatic reductions in surgical mortality and complications across diverse international hospitals. Surgical checklists have now become one of the clearest success stories in the patient safety movement, although some have described challenges to effective implementation. Dr. Atul Gawande discussed the history of checklists as a quality and safety tool in his book, The Checklist Manifesto: How to Get Things Right.

Journal Article > Study

Medication errors in a neonatal intensive care unit.

Lerner RB, de Carvalho M, Vieira AA, Lopes JM, Moreira ME. J Pediatr (Rio J). 2008;84:166-170.

A high incidence of medication errors was documented in a neonatal intensive care unit in Brazil.

Journal Article > Study

Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions.

Gommans J, McIntosh P, Bee S, Allan W. Intern Med J. 2008;38:243-248.

Periodic audit and feedback on prescribing errors resulted in near elimination of prescribing errors related to incorrect dosing or route of administration.

Journal Article > Study

Errors in the administration of intravenous medication in Brazilian hospitals.

Anselmi ML, Peduzzi M, Dos Santos CB. J Clin Nurs. 2007;16:1839-1847.

This cross-sectional study observed nursing staff prepare and administer intravenous medications. The authors report a low overall error rate with the most frequent types of errors associated with wrong dose and omission of dose.

Legislation/Regulation

Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag.

Information Exchange System Alert. Geneva, Switzerland: World Health Organization; July 18, 2007.

This international announcement provides guidance on the safe administration of the chemotherapeutic agent vincristine.

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