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Search results for "United States of America"

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Web Resource > Multi-use Website

Radiotherapy Incident Reporting and Analysis System.

Center for Assessment of Radiological Sciences.

Patient Safety Organizations enable robust data collection and analysis to support learning from medical error. This website of a Patient Safety Organization dedicated to radiation safety improvement offers a mechanism for voluntary reporting of radiation oncology incident data, a searchable database, and related publications.

Journal Article > Study

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

Armstrong GE, Dietrich M, Norman L, Barnsteiner J, Mion L. J Nurs Care Qual. 2017;32:226-233.

Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.

Journal Article > Study

Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative.

Bennett SC, Finer N, Halamek LP, et al. Jt Comm J Qual Patient Saf. 2016;42:369-376.

Checklists and debriefing improve patient safety across multiple care settings. In this quality improvement initiative, participating hospitals reported high levels of adherence and satisfaction to a protocol for neonatal resuscitation that included a checklist, briefings, and debriefings. The authors advocate for these safety processes to be included in neonatal resuscitation guidelines.

Journal Article > Study

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care.

Nguyen MC, Moffatt-Bruce SD, Strosberg DS, Puttmann KT, Pan YL, Eiferman DS. Surgery. 2016;160:858-868.

The AHRQ Patient Safety Indicators (PSIs) rely on hospital administrative data to screen for patient safety problems. This study used independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure) in identifying clinically significant patient safety events and found a positive predictive value of 38.3%. The authors argue that PSI 11 should not be used as a measure for hospital performance.

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.

Journal Article > Commentary

Recommended responsibilities for management of MR safety.

Calamante F, Ittermann B, Kanal E, Norris D; Inter-Society Working Group on MR Safety. J Magn Reson Imaging. 2016;44:1067-1106.

Magnetic resonance safety events can lead to serious patient harm. This commentary provides recommendations from expert consensus to help organizations design and implement a range of magnetic resonance imaging services. The authors also define three levels of management responsibilities required to support those recommendations in a various settings.

Journal Article > Study

Pediatric airway management and prehospital patient safety: results of a national Delphi survey by the Children's Safety Initiative-Emergency Medical Services for Children.

Hansen M, Meckler G, O'Brien K, et al. Pediatr Emerg Care. 2016;32:603-607.

Appropriate airway management is a key component of resuscitation in the prehospital setting. This study surveyed prehospital professionals to understand elements of prehospital pediatric airway management that may contribute to patient safety events. Investigators found that insufficient experience with pediatric airway management and difficulty deciding when an advanced airway should be performed were viewed as highly likely to lead to safety events.

Clinical Guideline

Society of Interventional Radiology IR Pre-Procedure Patient Safety Checklist by the Safety and Health Committee.

Rafiei P, Walser EM, Duncan JR, et al; Society of Interventional Radiology Health and Safety Committee. J Vasc Interv Radiol. 2016;27:695-699.

Most research has focused on developing and implementing checklists in surgical settings. This guideline recommends a set of pre-procedure checklist items and offers rationales for each to help hospitals develop a checklist for use in interventional radiology.

Web Resource > Government Resource

Interference between CT and Electronic Medical Devices.

Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration. April 12, 2016.

This website alerts clinicians and patients to risks for patient harm associated with implanted electronic medical devices, such as insulin infusion pump and pacemakers, when x-rays are used during CT examinations.

Journal Article > Commentary

Disclosure of medical errors involving gametes and embryos.

Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.

This publication advocates for open disclosure of errors in reproductive medicine.

Book/Report

Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.

US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.

Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.

Journal Article > Review

Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.

  • Classic

Paine CW, Goel VV, Ely E, et al. J Hosp Med. 2016;11:136-144.

Alarm safety is now a Joint Commission National Patient Safety Goal. This systematic review analyzed 24 studies on alarm characteristics and 8 studies that evaluated interventions to improve alert fatigue. The vast majority of the time, alarms do not signal problems that require clinician action. The most promising intervention strategies for reducing alarms that have emerged thus far are widening alarm parameters, implementing alarm delays, and frequently changing telemetry electrodes and wires.

Special or Theme Issue

Quality, Safety, and Noninterpretive Skills.

Kruskal JB, Kung JW, eds. Radiographics. 2015;35:1627-1848.

Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm for providers and patients. Articles in this special issue explore noninterpretive skills in radiologic practice, such as root cause analysis, professionalism, and error identification and reduction.

Journal Article > Study

In situ simulated cardiac arrest exercises to detect system vulnerabilities.

Barbeito A, Bonifacio A, Holtschneider M, Segall N, Schroeder R, Mark J; Durham Veterans Affairs Medical Center Patient Safety Center of Inquiry. Simul Healthc. 2015;10:154-162.

Realistic in situ simulations of cardiac arrest scenarios, conducted in actual clinical settings without advance notification of participants, identified several latent errors in a hospital's emergency response system. Dr. David Gaba, a pioneer in simulation in health care, was interviewed for AHRQ WebM&M in 2013.

Journal Article > Commentary

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2015;122:495-520.

This practice advisory summarizes the literature and expert opinion to advise practitioners on the dangers of administering anesthesia to patients receiving magnetic resonance imaging, or MRIs.

Web Resource > Multi-use Website

Radiation Oncology Incident Learning System.

American Society for Radiation Oncology and American Association of Physicists in Medicine.

Reporting of near misses and adverse events can provide a foundation for learning from error. This Web site supports an online portal facilitating incident reporting to enable data and experience analysis that will be used to inform development of guidelines and educational programs to promote safe practice in radiation oncology.

Journal Article > Study

A team-based approach to reducing cardiac monitor alarms.

Dandoy CE, Davies SM, Flesch L, et al. Pediatrics. 2014;134:e1686-e1694.

Improving alarm systems to mitigate the risks of alarm fatigue was added as a National Patient Safety Goal in the 2014 update. This study introduced a multifaceted cardiac monitor care process on a pediatric bone marrow transplant unit. The program included standardized steps for ordering and reassessing cardiac monitor parameters. In addition, physicians and nurses used a log to document the need for ongoing cardiac monitoring and created reliable systems for discontinuation of monitoring when it was no longer needed. Patients and families were actively engaged in these activities, helping sustain the program. As compliance with the process improved from 38% to 95%, the number of alarms per patient-day plummeted from 180 to 40. The hope is that reducing unnecessary alerts will address clinician desensitization to clinically important alarms.

Journal Article > Commentary

Saying "I'm sorry": error disclosure for ophthalmologists.

Lee BS, Gallagher TH. Am J Ophthalmol. 2014;158:1108-1110.

This commentary spotlights elements of ophthalmology practice that can influence error disclosure, particularly the prevalence of patients receiving care from optometrists outside the hospital environment with no central reporting mechanism.

Journal Article > Study

Analysis of adverse events associated with adult moderate procedural sedation outside the operating room.

Karamnov S, Sarkisian N, Grammer R, Gross WL, Urman RD. J Patient Saf. 2014 Sep 8; [Epub ahead of print].

The recent death of comedienne Joan Rivers, which followed a cardiac arrest during a routine throat procedure, has brought national attention to the potential safety hazards of office-based procedural anesthesia. This retrospective study examined adverse events associated with moderate procedural sedation performed outside of the operating room at a tertiary medical center. Adverse events were relatively rare, with only 52 safety incidents identified out of more than 140,000 cases over an 8-year period. The most common harm was oversedation leading to apnea and requiring the use of reversal agents or prolonged bag-mask ventilation. Women were found to be at particularly increased risk for adverse events including oversedation and hypotension. These findings suggest that a combination of patient and procedural characteristics may help risk stratify patients, allowing for appropriate responses such as increased monitoring and staffing for patients likely to experience sedation-related complications. A previous AHRQ WebM&M perspective described office-based anesthesia as the "Wild West" of patient safety.

Journal Article > Commentary

New enteral connectors: raising awareness.

Guenter P. Nutr Clin Pract. 2014;29:612-614.

Redesigning tubing connectors according to new ISO standards has the potential to reduce tubing misconnections. This commentary provides information about changes to enteral connectors to prepare clinicians to use the new devices in their organizations.

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