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Approach to Improving Safety
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Search results for "United States of America"

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Special or Theme Issue

Mistakes We Make in Dialysis.

Rodby RA, Perazella MA, eds. Semin Dial. 2016;29:253-328.

Insufficient application of new evidence to inform treatment decisions can hinder safe care delivery. Articles in this special issue explore common renal replacement management strategies that may need to be assessed and redesigned to improve the safety of patients receiving dialysis.

Tools/Toolkit > Government Resource

AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.

Rockville, MD: Agency for Healthcare Research and Quality; January 2015.

Health care–associated infections are a known contributor to adverse events among patients on dialysis. Building on evidence and insights from clinicians, this four-part toolkit includes videos, assessment tools, and slide presentations regarding how to apply principles of teamwork, patient engagement, and safety culture to ensure dialysis centers provide safe care to patients with end-stage renal disease.

Journal Article > Commentary

Maintaining safety in the dialysis facility.

Kliger AS. Clin J Am Soc Nephrol. 2015;10:688-695.

Failure to consider human factors and poor communication can contribute to dialysis treatment errors. This commentary discusses safety concerns in dialysis facilities, including medication errors, patient falls, and health care–associated infections. The authors recommend human factors engineering, patient engagement, and simulation as promising strategies to enhance safety in this setting.

Journal Article > Study

Patient safety culture in nephrology nurse practice settings: initial findings.

Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476.

This study utilized AHRQ patient safety culture surveys to assess nephrology nursing practices across the country. The survey revealed an overall interest in patient safety and teamwork, but also identified numerous areas for improvements, including handoffs, infection control, and medication errors.

Journal Article > Commentary

Bullying: a hidden threat to patient safety.

Longo J, Hain D. Nephrol Nurs J. 2014;41:193-199.

This commentary relates how bullying and other disruptive behaviors remain a pervasive issue in health care. The authors describe its impact on safety culture and highlight six standards to help address behaviors that hinder communication and transparency.

Journal Article > Study

Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study.

Reilly JB, Marcotte LM, Berns JS, Shea JA. Jt Comm J Qual Patient Saf. 2013;39:70-76.

In this study, communication between inpatient and outpatient dialysis units at discharge was highly variable.

Journal Article > Study

Error detection and recovery in dialysis nursing.

Wilkinson WE, Cauble LA, Patel VL. J Patient Saf. 2011;7:213-223.

This study found that expert nurses with more than 10 years of dialysis experience were more effective at detecting and correcting errors compared with non-experts, particularly for procedurally based errors.

Journal Article > Commentary

Optimizing patient safety during hemodialysis.

Himmelfarb J. JAMA. 2011;306:1707-1708.

This editorial discusses hemodialysis safety in the context of a concurrently published study [see link below]. The author describes how discoveries based on clinician experience can augment patient safety in this setting.

Journal Article > Study

A framework for evaluating the appropriateness of clinical decision support alerts and responses.

McCoy AB, Waitman LR, Lewis JB, et al. J Am Med Inform Assoc. 2012;19:346-352.

Increasing adoption of clinical decision support systems (CDSS) is driven by evidence that a well-designed system may impact provider behavior, medication safety, and patient outcomes. This study developed a framework to assess the clinical appropriateness of alerts, and applied the framework to alerts designed for patients with acute kidney injury. The authors identified rates of false positive alerts, alert overrides, provider non-adherence, and provider response appropriateness. Using their proposed framework, they advocate for systematic approaches to implementing and evaluating CDSS to optimize alert adherence and minimize alert overrides. A past AHRQ WebM&M commentary discussed integrating CDSS to improve medication safety.

Newspaper/Magazine Article

Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.

Boodman SG. Washington Post. June 13, 2011:E1.

This newspaper article reveals how biases and lack of trust in the patient/family perspective may contribute to diagnostic error.

Bibliography

Keeping Kidney Patients Safe.

Renal Physicians Association.

This Web site provides toolkits, educational modules, and an annotated bibliography to support quality improvement efforts for nephrology providers, and identifies best practice strategies for avoiding the Five Adverse Patient Safety Events in renal care.

Journal Article > Study

A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit.

Galhotra S, Devita MA, Dew MA, Simmons RL. Qual Saf Health Care. 2010;19:e38.

This review of rapid response system calls to an inpatient hemodialysis unit found that many events occurred before or after the dialysis session itself, implying that patient transportation to and from dialysis requires additional monitoring and safety measures.

Journal Article > Study

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

Terrell KM, Perkins AJ, Hui SL, Callahan CM, Dexter PR, Miller DK. Ann Emerg Med. 2010;56:623-629.

This study found that adding decision support to an existing computerized provider order entry system reduced the frequency of excessively dosed prescriptions by emergency physicians from 74% to 43%.

Newspaper/Magazine Article

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

ISMP Medication Safety Alert! April 8, 2010;15:1-3.

Detailing a recent lethal overdose of heparin, this piece describes common risks and offers suggestions to improve the safety of heparin administration.

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

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.

Field TS, Rochon P, Lee M, Gavendo L, Baril JL, Gurwitz JH. J Am Med Inform Assoc. 2009;16:480-485.

This study discovered that clinical decision support built within a CPOE system can improve physician prescribing behavior in long-term care settings.

Journal Article > Study

Chronic kidney disease adversely influences patient safety.

Seliger SL, Zhan M, Hsu VD, Walker LD, Fink JC. J Am Soc Nephrol. 2008;19:2414-2419.

This study found that patients with chronic kidney disease experienced more hospital adverse events as measured by AHRQ Patient Safety Indicators (PSIs). Similar to past research, the findings highlight the potential for specific preventive strategies that may benefit this patient population.

Newspaper/Magazine Article

FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels.

ISMP Medication Safety Alert! Acute Care Edition. June 19, 2008;13:1-3.

This article addresses a drug–device interaction in which patients receiving a certain peritoneal dialysis solution may have falsely elevated blood glucose levels when measured with point-of-care blood glucose monitors.

Journal Article > Commentary

A fatal case of iatrogenic hypercalcemia after calcium channel blocker overdose.

Sim MT, Stevenson FT. J Med Toxicol. 2008;4:25-29.

This case report documents an adverse event that resulted from treatment intended to reverse the effects of a medication overdose.

Journal Article > Study

Reducing preventable medication safety events by recognizing renal risk.

Fields W, Tedeschi C, Foltz J, et al. Clin Nurse Spec. 2008;22:73-78.

This study suggests that routine assessment of kidney function can reduce the risk of medication-related adverse events resulting from prescribing errors in patients with impaired creatinine clearance levels.

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