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"Medical error"

Kok Wai Kee, Cheryl Wai Teng Char, Anthony Yew Fei Yip
Introduction: Transition of care from hospital to primary care has been associated with increased medication errors. This review article aims to examine the existing evidence on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care. Methods: We systematically reviewed the articles in primary or ambulatory care setting on patients with care transition that involved medication safety, discrepancy, or error as outcome assessment...
May 2018: Journal of Family Medicine and Primary Care
Maya Aboumrad, Alexander Fuld, Christina Soncrant, Julia Neily, Douglas Paull, Bradley V Watts
PURPOSE: Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement...
August 15, 2018: Journal of Oncology Practice
John C Matulis, Frederick North
INTRODUCTION: Apologizing to patients is an encouraged practice, yet little is known about how and why providers apologize and what insights apologies could provide in improving quality and safety. OBJECTIVE: The aim of the study was to determine whether provider apologies in the electronic health record could identify patient safety concerns and opportunities for improvement. METHODS: After performing a free-text search, we randomly selected 100 clinical notes from 1685 available containing terminology related to apology...
July 17, 2018: Journal of Patient Safety
Indira Valadê Carvalho, Vanessa Marcilio de Sousa, Marília Berlofa Visacri, Júlia Coelho França Quintanilha, Cinthia Madeira de Souza, Rosiane Fátima Lopes Ambrósio, Marcelo Conrado Dos Reis, Rachel Alvarenga de Queiroz, Priscila Gava Mazzola, Taís Freire Galvao, Patricia Moriel
OBJECTIVES: The objectives of this study were to analyze adverse drug events (ADEs) related to admissions to a pediatric emergency unit and to identify the associated risk factors. METHODS: This was a prospective study. Demographic data and details of medications were collected for each patient admitted. Case studies were performed by clinical pharmacists and the clinical team to discuss whether the admission was due to an ADE and to characterize the ADE. Multivariate logistic regression was used for statistical analysis...
August 13, 2018: Pediatric Emergency Care
Lotta Schepel, Lasse Lehtonen, Marja Airaksinen, Raimo Ojala, Jouni Ahonen, Outi Lapatto-Reiniluoto
BACKGROUND: 10- 30% of hospital stays by older patients are drug-related. The admission phase is important for identifying drug-related problems, but taking an incorrect medication history often leads to medication errors. OBJECTIVES: To enhance medication history recording and identify drug-related problems (DRPs) of older patients admitted to emergency departments (EDs). METHODS: DRPs were identified by pharmacists-led medication reconciliation and review procedures in two EDs in Finland; Helsinki University Hospital (HUS), and Kuopio University Hospital (KUH)...
August 6, 2018: International Journal of Risk & Safety in Medicine
Amy Harig, Amy Rybarczyk, Amanda Benedetti, Jacob Zimmerman
Background: Vague, incomplete, or inaccurate drug-allergy histories can be detrimental to patient safety and affect patient care. There is an increased chance of medication errors if details of a drug allergy are not documented. Incomplete or inaccurate allergy histories may also result in increased time spent by health care providers to clarify an order in question. Published literature from the early 1990s showed that a patient interview can facilitate collection of more complete allergy information and could lead to the removal of a documented drug allergy in approximately one-third of patients...
August 2018: P & T: a Peer-reviewed Journal for Formulary Management
D Ks Au
No abstract text is available yet for this article.
August 2018: Hong Kong Medical Journal, Xianggang Yi Xue za Zhi
Peter J Gates, Sophie A Meyerson, Melissa T Baysari, Christopher U Lehmann, Johanna I Westbrook
: media-1vid110.1542/5799876436001PEDS-VA_2018-0805 Video Abstract CONTEXT: Patient harm resulting from medication errors drives prevention efforts, yet harm associated with medication errors in children has not been systematically reviewed. OBJECTIVE: To review the incidence and severity of preventable adverse drug events (pADEs) resulting from medication errors in pediatric inpatient settings. DATA SOURCES: Data sources included Cumulative Index of Nursing and Allied Health Literature, Medline, Scopus, the Cochrane Library, and Embase...
August 10, 2018: Pediatrics
Janne Cadamuro, Mercedes Ibarz, Michael Cornes, Mads Nybo, Elisabeth Haschke-Becher, Alexander von Meyer, Giuseppe Lippi, Ana-Maria Simundic
Background The inappropriate use of laboratory resources, due to excessive number of tests not really necessary for patient care or by failure to order the appropriate diagnostic test, may lead to wrong, missed or delayed diagnosis, thus potentially jeopardizing patient safety. It is estimated that 5-95% of tests are currently used inappropriately, depending on the appropriateness criteria, thus significantly contributing to the potential of generating medical errors, the third leading cause of death in the US...
August 10, 2018: Diagnosis
Barbara B Brewer, Kathleen M Carley, Marge M Benham-Hutchins, Judith A Effken, Jeffrey Reminga, Michael Kowalchuck
OBJECTIVE: The aim of this study was to compare information sharing and advice networks' relationships with patient safety outcomes. BACKGROUND: Communication contributes to medical errors, but rarely is it clear what elements of communication are key. METHODS: We investigated relationships of information-sharing and advice networks to patient safety outcomes in 24 patient care units from 3 hospitals over 7 months. Web-based questionnaires completed via Android tablets provided data to create 2 networks using ORA, a social network analysis application...
August 9, 2018: Journal of Nursing Administration
Clifford A Reilly, Sara Wiesel Cullen, Bradley V Watts, Peter D Mills, Douglas E Paull, Steven C Marcus
BACKGROUND: Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting. METHODS: The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient...
August 6, 2018: Joint Commission Journal on Quality and Patient Safety
Carolyn Hayes, Tamara Power, Patricia M Davidson, John Daly, Debra Jackson
AIM: To describe undergraduate nursing students' situational awareness and understanding of effective liaison and collaboration within the nursing team during interrupted medication administration. BACKGROUND: Medication errors related to interruptions are a major problem in health care, impacting on patient morbidity and mortality and increasing the burden of related costs. Effective liaison, teamwork and situation awareness are requisite skills for nurses to facilitate the safe management of interruptions during medication administration...
August 9, 2018: Contemporary Nurse
N Levy, G M Hall
The seventh National Diabetes Inpatient Audit (NaDIA) 2017 was published in March 2018, NaDIA is the annual snapshot audit of diabetes inpatient care in England and Wales. NaDIA 2017 found that 18% of hospital beds were occupied by a person with diabetes, an absolute increase of 3% from 2011. Moreover, the report identified that 4% of people with Type 1 diabetes mellitus developed the serious and preventable disorder of hospital-acquired diabetic ketoacidosis. Medication errors were common: 31% of people had at least one medication error, and this increased to 40% in those receiving insulin...
August 9, 2018: Diabetic Medicine: a Journal of the British Diabetic Association
Doris George, Amar-Singh Hss, Azmi Hassali
Background and objectives In Malaysia, the national voluntary non-punitive Medication Error Reporting System (MER-S) has been available since 2009, with compiled reports indicating the underreporting of various medication errors (ME). This survey intends to determine the ME reporting practice among healthcare professionals and the acceptance of ME reporting by utilising smartphone application if it is available. Design A cross-sectional survey was conducted for two months in 2017 among doctors and pharmacists in publicly funded healthcare facilities in Perak, Malaysia...
June 5, 2018: Curēus
Carlotta Piccardi, Jens Detollenaere, Pierre Vanden Bussche, Sara Willems
BACKGROUND: Patient safety is a quality indicator for primary care and it should be based on individual needs, and not differ among different social groups. Nevertheless, the attention on social disparities in patient safety has been mainly directed towards the hospital care, often overlooking the primary care setting. Therefore, this paper aims to synthesise social disparities in patient safety in the primary care setting. METHODS: The Databases PubMed and Web of Science were searched for relevant studies published between January 1st 2006 and January 31st 2017...
August 7, 2018: International Journal for Equity in Health
Tenielle Watkins, Sandra M Aguero, Michael Jaecks
Failure to appropriately document patient medical information, such as allergies, is an important cause of medication errors. Lack of allergy details in the electronic medical record (EMR) may prolong the pharmacist order verification process. A retrospective chart review was conducted in October 2017, to evaluate the impact of incomplete allergy details on time to antibiotic order resolution at the Einstein Medical Center Philadelphia. Details were present on 71% of orders. The difference in median time to order resolution, for orders with versus without details, was ⁻21 min (95% CI (confidence interval), ⁻39 to ⁻2...
August 3, 2018: Pharmacy (Basel, Switzerland)
Fatima Schera, Michael Schäfer, Anca Bucur, Jasper van Leeuwen, Eric Herve Ngantchjon, Norbert Graf, Haridimos Kondylakis, Lefteris Koumakis, Kostas Marias, Stephan Kiefer
Clinical decision support systems can play a crucial role in healthcare delivery as they promise to improve health outcomes and patient safety, reduce medical errors and costs and contribute to patient satisfaction. Used in an optimal way, they increase the quality of healthcare by proposing the right information and intervention to the right person at the right time in the healthcare delivery process. This paper reports on a specific approach to integrated clinical decision support and patient guidance in the cancer domain as proposed by the H2020 iManageCancer project...
2018: Ecancermedicalscience
J Arimany Manso, C Martin Fumadó, J M Mascaró Ballester
Clinical safety and medical liability are first-order concerns in today's medical practice. It is important to understand the circumstances under which medical acts fail to live up to the accepted standard of care and to recognize the impact that malpractice claims have on physicians. Practitioners must also grasp the concept of medical error, studying malpractice claims in order to identify the areas where improvement is needed. The risk of accusations of malpractice in dermatology is comparatively low, both in Spain and worldwide...
August 1, 2018: Actas Dermo-sifiliográficas
D Baumann, N Dibbern, S Sehner, C Zöllner, W Reip, J C Kubitz
Medication errors occur frequently and are a risk to patient safety. To reduce mistakes in the medication process in emergencies, a mobile app has been developed supporting the calculation of doses and administration of drugs. A simulation study was performed to validate the app as a tool to reduce medication errors. This was a randomised crossover study conducted in the Academic Hospital. The participants included were residents and attendings in anaesthesiology. 74 Participants performed four simulation scenarios in which they had to calculate and administer drugs for emergencies...
August 2, 2018: Journal of Clinical Monitoring and Computing
Frank Moriarty, Kathleen Bennett, Tom Fahey
OBJECTIVE: While fixed-dose combinations (FDC) can improve adherence, they may add complexity to the prescribing/dispensing process, potentially increasing risk of medication errors. This study aimed to determine if prescriptions for antihypertensive FDCs increase the risk of therapeutic duplication and drug-drug interactions (DDI). METHODS: This retrospective observational study used administrative pharmacy claims data from the Irish Primary Care Reimbursement Service...
August 2, 2018: Heart: Official Journal of the British Cardiac Society
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