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Search results for "Education and Training"

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Newspaper/Magazine Article

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

This article discusses incidents involving misadministration of IV insulin and makes recommendations to improve safety in delivering this high-alert medication.

Journal Article > Study

Differences in medication knowledge and risk of errors between graduating nursing students and working registered nurses: comparative study.

Simonsen BO, Daehlin GK, Johansson I, Farup PG. BMC Health Serv Res. 2014;14:580.

Nursing skill mix and training may be linked to patient outcomes, and one study showed lower inpatient mortality rates for a variety of surgical patients in hospitals with more highly educated nurses. In this study, practicing nurses had greater medication knowledge than graduating nursing students, but both groups had serious deficiencies, particularly in their ability to perform drug dose calculations correctly.

Press Release/Announcement

Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010.

Rockville, MD: US Food and Drug Administration; November 9, 2010.

This notice analyzes findings from a government initiative on CT scan injuries and provides recommendations to enhance safety and prevent such incidents.

Journal Article > Study

An intervention to decrease patient identification band errors in a children's hospital.

Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.

Patient misidentification errors are surprisingly common, as demonstrated in studies in the inpatient and emergency department settings. In this study, a children's hospital conducted a continuous quality improvement intervention to reduce misidentification errors. Interventions—many of which were suggested by staff—included wristband standardization and a "stop-the-line" policy if a misidentification error was suspected. The project resulted in a significant and sustained reduction in these errors. An AHRQ WebM&M commentary discusses a near miss that occurred due to a misidentification error in the labeling of phlebotomy specimens.

Journal Article > Study

Medication errors recovered by emergency department pharmacists.

Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.

In this direct observation study, emergency department pharmacists identified approximately one actual or potential medication error per 13 patients.

Journal Article > Study

A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims.

Simpson KR, Kortz CC, Knox E. Jt Comm J Qual Patient Saf. 2009;35:565-574.

An organization-wide quality improvement program resulted in reductions in perinatal adverse events over a 5-year period.

Press Release/Announcement

Relenza (zanamivir) inhalation powder.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.

This alert notifies health care providers of the potential for patient harm if a particular inhalation powder is reconstituted and incorrectly administered.

Journal Article > Review

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

Radiation oncology is one of the more technologically sophisticated fields in medicine, requiring close collaboration between physicians, technologists, and medical physicists. High-profile errors in this field have been attributed to rapidly changing technology and human factors, and this review sought to characterize the types and frequency of errors and near misses in routine radiotherapy practice using data from voluntary error databases as well as published literature. Although the overall incidence of errors appears low, most reported errors were considered preventable, as they occurred due to faulty information transfer. The authors discuss the types of errors that may occur at each stage of radiotherapy and recommend error prevention strategies.

Journal Article > Study

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

Lee BH, Lehmann CU, Jackson EV, et al. J Pain. 2009;10:160-166.  

Medication errors are a common problem in pediatric outpatients, and high-alert medications such as opioid analgesics are a major cause of emergency department visits in both children and adults. This study evaluated the quality of analgesic prescriptions in patients being discharged from a pediatric teaching hospital. Most prescriptions contained at least one error, including frequent use of error-prone abbreviations and failure to use weight-based dosing, and 3% of prescriptions were judged to have the potential for serious patient harm. Computerized provider order entry (CPOE) has been advocated as a means of preventing medication errors in children, but in a prior study, CPOE actually failed to reduce dosing errors in children.

Cases & Commentaries

Mark My Tooth

  • Web M&M

Richard A. Smith, DDS; July-August 2007

A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.

Journal Article > Study

Anaesthetists' management of oxygen pipeline failure: room for improvement.

Weller J, Merry A, Warman G, Robinson B. Anaesthesia. 2007;62:122-126.

The investigators observed anesthetists in a simulated environment and analyzed their ability to respond to a central oxygen supply failure.

Journal Article > Commentary

Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.

Hearns S, Shirley PJ. Emerg Med J. 2006;23:943-947.

The authors describe the retrieval and transfer of critically ill patients from one environment to another and provide recommendations for making this process as safe and reliable as possible.

Journal Article > Review

Nature of human error: implications for surgical practice.

Cuschieri A. Ann Surg. 2006;244:642-648.

The authors analyzed the literature to identify important components of safe surgical care and determine what research is needed to deepen the understanding of how human error affects surgical practice.

Journal Article > Study

Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance.

Rennie W, Phetsouvanh R, Lupisan S, et al. Trans R Soc Trop Med Hyg. 2006;101:9-18.

The authors describe the development of an instructional protocol to increase the reliability of rapid diagnostic testing of malaria.

Newspaper/Magazine Article

Skin tears: the clinical challenge.

PA-PSRS Patient Saf Advis. September 2006;3:1, 5-10.

This article discusses the Pennsylvania Patient Safety Reporting System (PA-PSRS) reports of skin tears and provides suggestions to help keep patients safe from this common injury.

Cases & Commentaries

Physical Diagnosis: A Lost Art?

  • Spotlight Case
  • Web M&M

George R. Thompson III, MD, and Abraham Verghese, MD; August 2006

A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.

Book/Report

Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened.

Washington, DC: United States Government Accountability Office; June 2006. Publication GAO-06-416.

This government report found that the clinical laboratory survey process is flawed, allowing safety requirements to be bypassed.

Journal Article > Commentary

Improving patient safety in hospitals: contributions of high-reliability theory and normal accident theory.

Tamuz M, Harrison MI. Health Serv Res. 2006;41:1654-1676.

The authors apply normal accident theory and high-reliability theory to several patient safety improvement strategies (eg, crew resource management) and assess how the theories contribute to these popular patient safety practices.

Cases & Commentaries

Collegiality vs. Competence

  • Web M&M

Todd Sagin, MD, JD; March 2006

Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.

Journal Article > Commentary

Renewal of surgical quality and safety initiatives: a multispecialty challenge.

Polk HC Jr. Mayo Clinic Proc. 2006;81:345-352.

The author presents both national and regional activities supporting progress in surgical quality and safety.

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