Search results for "United States of America"

This study assessed an error of omission—failure to assess children for occult fractures—in several clinically indicated situations, and found that such errors occur in about half of cases. Interventions to prompt specific actions, like checklists, may be useful in this clinical arena.

This commentary describes human factors, usability, and informatics recommendations for electronic health records in pediatrics to improve their usefulness and reduce the risk of errors.

Medication reconciliation was initially established as a National Patient Safety Goal (NPSG) in 2005. However, difficulty establishing and implementing effective medication reconciliation approaches led to The Joint Commission suspending evaluation of this NPSG in 2009 and eventually eliminating it as a separate NPSG in 2011. This report from a large health care system provides a detailed template for integrating medication reconciliation into clinician workflow in the outpatient setting. Through a combination of leadership engagement, rapid cycle quality improvement projects, and financial incentives, the organization achieved consistent and sustained improvement in documentation of medication reconciliation for pediatric patients over a 5-year period. As medication reconciliation has been less studied in the ambulatory care setting, this study provides a useful window into the barriers inherent in changing outpatient clinician workflow and the steps this organization took to minimize unintended consequences of the intervention.

Improving teamwork and communication is a continued focus in the hospital setting. Targeted interventions to address noted gaps include adoption of interdisciplinary rounds, use of patient whiteboards, and structured tools such as SBAR. This study reorganized physicians into unit-based teams to evaluate the impact on nurse–physician communication. Following implementation of the new model, physicians were more likely to identify the nurse for their patients and experience increased frequency of direct communication with them. These changes also led to 42% fewer pages from nurses to physicians. While the study didn't correlate these self-reported improvements in communication to clinical outcomes, it's one of the first studies investigating the benefits of geographic organization as a potential safety strategy.

Pediatric medication errors are common yet studied less in the ambulatory setting than in the inpatient arena. This prospective cohort study of six outpatient practices identified more than 1200 medication errors with minimal potential for harm, and more than 460 potentially harmful ones deemed near misses. Overall, a remarkable half of all prescriptions had errors and a fifth of those had potential for harm. The authors were particularly interested in understanding the differences between errors with minimal potential for harm and near misses. The prescribing stage was responsible for nearly 95% of the errors in the former category but only 60% of the latter. Whereas inappropriate abbreviations were the most common cause in the minimal harm group, dosing errors were most common in the near misses. Their findings suggest that e-prescribing may effectively address many of the issues identified, particularly around provider illegibility, but further solutions will also be needed.

This narrative illustrates potential dangers and delays that may result from inadequate confirmation of contact mechanisms and protocols for patient follow-up.

Efforts to develop health literacy interventions are one strategy to improve medication safety. In pediatric populations, the need for parents to understand liquid medication dosing poses additional risks. This study evaluated the role of dosing instrument type (e.g., cups, droppers, syringes) on parents' medication administration errors. Investigators found that dosing accuracy was lowest when using cups, and that cups were also associated with the largest deviations in dosing errors administered. Limited health literacy was also associated with parents' dosing errors. The Joint Commission has published recommendations for improving patient–provider communication to address safety problems caused by low health literacy, an example of which is discussed in an AHRQ WebM&M commentary. Accompanying this article [see link below] is an Advice for Patients educational page that highlights pearls for medication safety in children.

This survey revealed that many adults do not understand instructions for common liquid prescription medications, potentially increasing the risk of serious medication errors. Prior research in this field has demonstrated that low health literacy is an important predictor of misunderstanding prescription instructions. Concerningly, in this study nearly 1 in 5 patients who had adequate health literacy could not correctly interpret the instructions, and patients with marginal or low health literacy were at even greater risk. The Joint Commission has published recommendations for improving patient–provider communication to address safety problems caused by low health literacy, an example of which is discussed in an AHRQ WebM&M commentary.

According to this analysis of data from 1995 to 2005, nearly 600,000 physician visits yearly are attributable to adverse drug events (ADEs) in children. As documented in earlier research, immunosuppressive and chemotherapy medications were associated with the highest risk of an ADE. Prior studies have found that many ADEs in children are attributable to incorrect medication administration by parents, and parental education has been investigated as a means of preventing such errors. A case of parental error in administering medication to an infant is discussed in this AHRQ WebM&M commentary.

The US Food and Drug Administration discourages the use of over-the-counter cold medications in children younger than 2 years. Despite this, most parents in this study thought such medications were entirely appropriate for their infants, and appeared to be unduly influenced by the product labeling and graphics. Prior research has identified low health literacy as a prominent risk factor for misinterpreting prescription drug labels. This study also found that limited numeracy (the ability to apply arithmetic operations to everyday tasks) was a risk factor for incorrectly interpreting the product labeling. A prior trial used pictorial displays to explain medication dosing in children and resulted in fewer errors and improved adherence.

Focus groups with primary care physicians identified several barriers to increased use of electronic prescribing. These included excessive and confusing drug alerts and unreimbursed costs.

Implementation of information technology solutions for following up on test results improved reliability and provider satisfaction. However, clinics that only partially implemented such systems reported decreased efficiency and greater concern about patient safety issues.

Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.

This population-based study revealed that approximately 30 infants per year in California die due to missed diagnoses of congenital heart disease. Screening for specific disorders should be performed at the first postdischarge pediatrician visit.

This article describes how medical errors may cause serious harm in pediatric patients and offers tips for hospitals and parents to foster safe treatment.

This study used MEDMARX data to characterize medication errors in the prescribing of medications for the treatment of attention deficit hyperactivity disorder. Most errors were detected by pharmacists and were committed at the prescribing stage.

Regulations intended to reduce resident physicians' work hours have been accompanied by controversy since their introduction in 2003. Although large-scale studies have demonstrated that the regulations were not associated with adverse clinical outcomes, their effect on patient safety remains unclear. This prospective cohort study combined data on actual hours worked and burnout (voluntarily reported by pediatric residents at three hospitals), with data on medication errors gathered through active surveillance. The most notable finding was that, despite the regulations, residents' total hours worked and sleep habits did not change. Extended-duration shifts (of more than 24 hours) remained common, and the majority of residents met the criteria for burnout, although the incidence did decrease. Medication errors and self-reported medical errors did not improve. The authors interpret these findings as demonstrating a need for further reduction in extended-duration shifts, which have been associated with an increased rate of errors.

This article discusses the development of indicators to monitor the quality of care for hospitalized children, based on AHRQ's Quality Indicators for adult hospitals.

This prospective multicenter observational study sought to quantify the risk of procedural sedation in children, in whom sedation is much more commonly used than in adults. The participating institutions voluntarily submitted data on more than 30,000 encounters and found that the overall risk of serious adverse events was much lower than that seen in a prior single-center study. However, adverse events with the potential for harm (near misses), such as unanticipated need for bag-mask ventilation or reversal of anesthesia, occurred in 1 of 89 cases. The authors note that, owing to the voluntary nature of the database, these data may be closer to "best practice" than the typical community experience.

This study examined data from a voluntary medication error reporting system (Medmarx) to determine the incidence of harmful pediatric medication errors, the classes of medications frequently associated with error, and the types of errors that occurred. Harmful errors were defined as errors that resulted in temporary or permanent harm to the patient or required immediate intervention to avoid harm. Opioid analgesics, antimicrobials, and antidiabetic agents were most commonly associated with harmful medication errors, collectively accounting for 23.5% of the errors reported. The major type of error was administration at an incorrect dose or quantity (especially for opioid analgesics), followed by omission errors. These findings are similar to those of a previous study. The authors review the systems factors contributing to common medication errors and suggest strategies for error prevention.