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Search results for "Hospitals"

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Cases & Commentaries

The Perils of Contrast Media

  • Spotlight Case
  • CME/CEU
  • Web M&M

Umar Sadat, MD, PhD, and Richard Solomon, MD; June 2017

To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

Journal Article > Commentary

Investigating the causes of adverse events.

Sanchez JA, Lobdell KW, Moffatt-Bruce SD, Fann JI. Ann Thorac Surg. 2017;103:1693-1699.

Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.

Journal Article > Commentary

Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education.

Charles R, Hood B, DeRosier JM, et al. Orthopedics. 2017 Apr 24; [Epub ahead of print].

This commentary highlights the importance of engaging residents in root cause analysis of errors and near misses. The authors discuss how participation in root cause analysis can educate trainees about process analysis and augment skill development.

Journal Article > Commentary

Elimination of emergency department medication errors due to estimated weights.

Greenwalt M, Griffen D, Wilkerson J. BMJ Qual Improv Rep. 2017;6:u214416.w5476.

Inaccurate assessments of patient weight can lead to medication dosing errors. This commentary describes how a single-center quality improvement project drew from errors in the emergency department associated with incorrect patient weight estimates and applied storytelling, Lean Six Sigma, and Fishbone diagram approaches to develop and test a method of entering weights that eliminated these errors during the 6-month intervention period.

Cases & Commentaries

Consequences of Medical Overuse

  • Spotlight Case
  • CME/CEU
  • Web M&M

Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

Journal Article > Commentary

Root-cause analysis: swatting at mosquitoes versus draining the swamp.

Trbovich P, Shojania KG. BMJ Qual Saf. 2017;26:350-353.

Although root cause analysis is an established strategy to investigate incidents, some have questioned its effectiveness in health care. Drawing from a recent study, this editorial suggests that robust health care investment in human factors engineering and safety science is needed to help root cause analysis achieve its full potential as an improvement mechanism. A recent Annual Perspective discussed ongoing problems with the root cause analysis process and described opportunities to improve its application in health care.

Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

Journal Article > Commentary

Management of a patient with a latex allergy.

Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.

This case analysis discusses the use of a latex catheter in a patient with a known latex allergy and presents how root cause analysis identified factors that contributed to the error. Recommended corrective actions included educating staff about latex allergies and using a checklist to address communication, documentation, and process weaknesses.

Journal Article > Study

Medication errors associated with transition from insulin pens to insulin vials.

Trimble AN, Bishop B, Rampe N. Am J Health Syst Pharm. 2017;74:70-75.

Insulin is a high-risk medication. This pre–post study examined the risk for insulin dosing errors after a transition from insulin pens to vials. Three major insulin administration errors occurred, which led to training and process changes in order to mitigate the risk of harm.

Perspectives on Safety > Annual Perspective

Rethinking Root Cause Analysis

with commentary by Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD, 2016

Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.

Journal Article > Study

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

Kellogg KM, Hettinger Z, Shah M, et al. BMJ Qual Saf. 2017;26:381-387.

Root cause analysis (RCA) is a process frequently employed by health care institutions to understand the sequence of events leading to an adverse event or near miss. Experts have previously highlighted flaws with the RCA process and suggested ways to improve it. In this study, researchers reviewed 302 RCAs and concluded that many of the proposed solutions were weak, consisting largely of educational interventions, changes to processes, and enforcing policy. A recent Annual Perspective explores ongoing problems with the RCA process and sheds light on opportunities to improve its application in health care.

Perspectives on Safety > Perspective

Errors and Near Misses: What Health Care Could Learn From Aviation

with commentary by Carl Macrae, PhD, Root Cause Analysis: What Have We Learned?, December 2016

This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.

Perspectives on Safety > Interview

In Conversation With... James P. Bagian, MD, PE

Root Cause Analysis: What Have We Learned?, December 2016

Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, and a former astronaut. He co-chaired the team that produced the influential NPSF report entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

Book/Report

Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project.

Chicago, IL: Health Research & Educational Trust; October 2016.

Falls are a common hazard among both hospitalized and ambulatory patients. This report summarizes the results of a collaborative to identify and address the root causes of falls in hospitals and provides case studies from the participating organizations to illustrate their experiences during the initiative.

Journal Article > Review

How to perform a root cause analysis for workup and future prevention of medical errors: a review.

Charles R, Hood B, Derosier JM, et al. Patient Saf Surg. 2016;10:20.

Root cause analysis is a widely used strategy for understanding failure in patient care. This review highlights a root cause analysis method and describes tools such as story maps and cause-and-effect diagrams that support the use of this structured approach to examine process weaknesses and implement improvements.

Journal Article > Commentary

Performing the wrong procedure.

Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.

Describing an incorrect procedure incident which involved placement of a dialysis catheter instead of a central line, this commentary outlines the root causes of the event and how it could have been prevented. A related editorial introduces Performance Improvement, a series of case-based articles intended to support frontline performance improvement efforts.

Journal Article > Commentary

The problem with the '5 whys.'

Card AJ. BMJ Qual Saf. 2016 Sep 2; [Epub ahead of print].

Investigation of incidents in complex systems can be hindered by time limitations, lack of follow-up, and incomplete resolution. This commentary discusses a commonly used tool to identify root causes of problems. The author highlights its value as a teaching tool but notes that its use for root cause analysis in health care may be misguided as it tends to simplify complex problems and limit understanding of how processes fail.

Cases & Commentaries

Complaints as Safety Surveillance

  • Web M&M

Jennifer Morris and Marie Bismark, MD; September 2016

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Tools/Toolkit > Fact Sheet/FAQs

How to Improve Electronic Health Record Usability and Patient Safety.

Philadelphia, PA: Pew Charitable Trusts; September 6, 2016.

The usability of electronic health record (EHR) systems can affect clinicians' ability to provide safe patient care. This fact sheet summarizes the results of a stakeholder meeting that explored usability problems and identified three improvement strategies that focused on effective testing, user assessment of EHR safety, and sharing of lessons learned.

Journal Article > Study

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

van Galen LS, Struik PW, Driesen BEJM, et al. PLoS One. 2016;11:e0161393.

Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.

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