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Search results for "Hospitals"

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Cases & Commentaries

The Hidden Harms of Hand Sanitizer

  • Web M&M

Stephen Stewart, MBChB, PhD; July 2017

Hospitalized for pneumonia, a woman with a history of alcohol abuse and depression was found unconscious on the medical ward. A toxicology panel revealed her blood alcohol level was elevated at 530 mg/dL. A search of the ward revealed several empty containers of alcoholic foam sanitizer, which the patient confessed to ingesting.

Journal Article > Study

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. BMJ Qual Saf. 2017 Feb 23; [Epub ahead of print].

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Journal Article > Study

Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet.

Harada S, Suzuki A, Nishida S, et al. J Eval Clin Pract. 2017;23:582-585.

Insulin is known to be a high-risk medication. This pre–post study found that introduction of a standardized sliding scale insulin order led to decreased rates of insulin prescribing errors. However, the incidence of hyperglycemia or hypoglycemia did not change. This study demonstrates how standardization can support patient safety.

Journal Article > Study

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-571.

Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.

Journal Article > Study

More than just crushing: a prospective pre-post intervention study to reduce drug preparation errors in patients with feeding tubes.

Lohmann K, Gartner D, Kurze R, et al. J Clin Pharm Ther. 2015;40:220-225.

Crushing pills or capsules is sometimes necessary when a patient is not capable of swallowing normally, but this can also be a source of medication errors. This study, conducted in a university hospital in Germany, demonstrated a significant reduction in inappropriate crushing of medications after an intensive educational program.

Journal Article > Study

Intercepting wrong-patient orders in a computerized provider order entry system.

Green RA, Hripcsak G, Salmasian H, et al. Ann Emerg Med. 2015;65:679-686.

While computerized physician order entry is expected to significantly reduce adverse drug events, systems must be implemented thoughtfully to avoid facilitating certain types of errors. A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient prescribing errors within a computerized provider order entry system.

Journal Article > Review

Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU?

Weiss CH, Wunderink RG. Curr Opin Crit Care. 2013;19:448-452

This review evaluates the use of checklists coupled with forcing functions in the intensive care unit as a strategy to enhance appropriate antibiotic use.

Journal Article > Study

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

A quality improvement process that included forcing functions resulted in significantly improved adherence to the Universal Protocol for prevention of wrong-site procedures.

Journal Article > Study

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

Coleman JJ, Hemming K, Nightingale PG, et al. J R Soc Med. 2011;104:208-218.

Hard stop alerts within computerized provider order entry (CPOE) systems are intended to avert serious medication errors by preventing prescribing of contraindicated medications. This study investigated whether data from a CPOE system could be used to identify individual physicians who commit more frequent prescribing errors. However, the study found that trainee physicians who committed errors prompting hard stop alerts were not more likely to commit less serious prescribing errors, nor did they appear to ignore prescribing warnings more frequently. Although objective performance data would help identify doctors who frequently make prescribing errors, this study's results indicate that triggering of CPOE alerts is not a reliable measure.

Journal Article > Study

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

  • Classic

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

Computerized provider order entry (CPOE) systems prevent prescribing errors by warning clinicians about medication interactions or contraindications. However, extensive research has shown that clinicians ignore many warnings, especially those perceived as clinically inconsequential. In this randomized trial, investigators created a "hard stop" warning that essentially prevented co-prescribing of warfarin and trimethoprim-sulfamethoxazole (a combination that exposes patients to severe bleeding risks). Although the hard stop was much more successful than a less stringent warning at preventing co-prescribing, the trial was stopped and the warning abandoned because several patients experienced delays in needed treatment with one of the drugs. The accompanying editorial by Dr. David Bates points out that this study vividly illustrates the unintended consequences of CPOE, a persistent issue that has slowed the pace of CPOE implementation.

Journal Article > Commentary

A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders.

Tarpey K, Schaaf E, Lakhani U, Balcitis J. Jt Comm J Qual Patient Saf. 2010;36:461-467.

Although sound-alike medications are a well-recognized source of errors, this study addresses a little-studied problem—sound-alike physician names. As the article notes, only 24% of practicing physicians in the United States have a unique last name, raising the potential for errors associated with physician misidentification. When the issue was raised by a physician with a common last name during executive walk rounds, the institution conducted a failure modes effect analysis that identified several critical flaws in the physician identification process. Solutions implemented as a result included forcing functions within the electronic medical record, ensuring that orders and test results could not be misassigned to similarly named physicians.

Journal Article > Commentary

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

Evans AS, Lazar EJ, Tiase VL, et al. Am J Med Qual. 2011;26:39-42.

This article details how one academic medical center engaged housestaff in tactics to achieve higher compliance with medication reconciliation.

Cases & Commentaries

"Superficial" Report Leads to "Deep" Problem

  • Web M&M

Gurpreet Dhaliwal, MD; December 2009

Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.

Journal Article > Study

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

Patients hospitalized for cardiac problems are vulnerable to experiencing medication errors, as they are commonly prescribed high-risk medications such as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for example, angioplasty) found that 22.3% were administered either enoxaparin or eptifibatide, medications that are contraindicated in dialysis patients due to excessive bleeding risk. This risk was borne out in the study, as patients who received the contraindicated medications did in fact have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications.

Journal Article > Study

Identifying opportunities for quality improvement in surgical site infection prevention.

Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Am J Infect Control. 2009;37:398-402.

This study conducted interviews with surgical division heads and managers of quality improvement and infection control at seven hospitals to highlight thematic strategies for preventing surgical site infections. The authors advocate for a combination of educational initiatives, performance data, explicit accountabilities that trigger action, and engaged champions to succeed in the team-oriented effort.

Cases & Commentaries

Double Dosing, by the Rules

  • Web M&M

Hedy Cohen, RN, BSN, MS; February-March 2009

New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.

Newspaper/Magazine Article

Medication errors associated with documented allergies.

PA-PSRS Patient Saf Advis. September 2008;5:75-80.

This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.

Journal Article > Study

Errors with concentrated epinephrine in otolaryngology.

Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008;118:1928-1930.

This survey revealed that many otolaryngologists have witnessed medication errors due to incorrect administration of concentrated epinephrine during surgery.

Journal Article > Study

Use of a computerized forcing function improves performance in ordering restraints.

Griffey RT, Wittels K, Gilboy N, McAfee AT. Ann Emerg Med. 2009;53:469-476.

Computerized reminders to renew orders for physical restraints were combined with a forcing function—denial of computer access until the order was completed—in this trial conducted in an emergency department. Although clinician ordering behavior improved, no significant improvement was found in the amount of time patients spent in restraints.

Journal Article > Review

Requirements for the design and implementation of checklists for surgical processes.

Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Surg Endosc. 2009;23:715-726.

This review combines evidence and insights from the authors' experience to describe requirements in developing and implementing a surgical care checklist.

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