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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/28728430/patient-handoff-education-are-medical-schools-catching-up
#1
Robyn Davis, Joshua Davis, Katherine Berg, Dale Berg, Charity J Morgan, Stefani Russo, Lee Ann Riesenberg
Communication errors during shift-to-shift handoffs are a leading cause of preventable adverse events. Nevertheless, handoff skills are variably taught at medical schools. The authors administered questionnaires on handoffs to interns during orientation. Questions focused on medical school handoff education, experiences, and perceptions. The majority (546/718) reported having some form of education on handoffs during medical school, with 48% indicating this was 1 hour or less. Most respondents (98%) reported that they believe patients experience adverse events because of inadequate handoffs, and more than one third had witnessed a patient safety issue...
July 1, 2017: American Journal of Medical Quality: the Official Journal of the American College of Medical Quality
https://www.readbyqxmd.com/read/28678068/anesthesia-adverse-events-voluntarily-reported-in-the-veterans-health-administration-and-lessons-learned
#2
Julia Neily, Elda S Silla, Sam John T Sum-Ping, Roberta Reedy, Douglas E Paull, Lisa Mazzia, Peter D Mills, Robin R Hemphill
BACKGROUND: Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions...
July 1, 2017: Anesthesia and Analgesia
https://www.readbyqxmd.com/read/28668911/recognizing-the-ordinary-as-extraordinary-insight-into-the-way-we-work-to-improve-patient-safety-outcomes
#3
Elizabeth A Henneman
The Institute of Medicine (now National Academy of Medicine) reports "To Err is Human" and "Crossing the Chasm" made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the "near miss" process and as the final safety net for the patient is of paramount importance...
July 2017: American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses
https://www.readbyqxmd.com/read/28661998/description-and-yield-of-current-quality-and-safety-review-in-selected-us-academic-emergency-departments
#4
Richard Thomas Griffey, Ryan M Schneider, Brian R Sharp, Jeffrey J Pothof, Sheridan Hodkins, Roberta Capp, Jennifer L Wiler, Neil Sreshta, John E Sather, Christopher S Sampson, Jonathan T Powell, Kathryn Y Groner, Lee M Adler
OBJECTIVES: Quality and safety review for performance improvement is important for systems of care and is required for US academic emergency departments (EDs). Assessment of the impact of patient safety initiatives in the context of increasing burdens of quality measurement compels standardized, meaningful, high-yield approaches for performance review. Limited data describe how quality and safety reviews are currently conducted and how well they perform in detecting patient harm and areas for improvement...
June 29, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28618102/factors-contributing-to-serious-adverse-events-in-nursing-homes
#5
Åsa Andersson, Catharina Frank, Ania M L Willman, Per-Olof Sandman, Görel Hansebo
AIMS AND OBJECTIVES: The aim of this study was to identify the most common serious adverse events that occurred in nursing homes and their most frequent contributing factors to contribute to improvement of safe nursing care. BACKGROUND: There is a need to improve safe nursing care in nursing homes. Residents are often frail and vulnerable with extensive needs for nursing care. A relatively minor adverse event in nursing care can cause serious injury that could have been preventable...
June 15, 2017: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/28574959/intravenous-smart-pump-drug-library-compliance-a-descriptive-study-of-44-hospitals
#6
Karen K Giuliano, Wan-Ting Su, Daniel D Degnan, Kristy Fitzgerald, Richard J Zink, Poching DeLaurentis
BACKGROUND: Although intravenous (IV) smart pumps with built-in dose-error reduction systems (DERS) can reduce IV medication administration error, most serious adverse events still occur during IV medication administration. Sources of error include overriding DERS and manually bypassing drug libraries and the DERS. METHODS: Our purpose was to use the Regenstrief National Center for Medical Device Informatics data set to better understand IV smart pump drug library and DERS compliance...
June 1, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28550926/restrictions-on-surgical-resident-shift-length-does-not-impact-type-of-medical-errors
#7
Jamie E Anderson, Laura F Goodman, Guy W Jensen, Edgardo S Salcedo, Joseph M Galante
BACKGROUND: In 2011, resident duty hours were restricted in an attempt to improve patient safety and resident education. With the goal of reducing fatigue, shorter shift length leads to more patient handoffs, raising concerns about adverse effects on patient safety. This study seeks to determine whether differences in duty-hour restrictions influence types of errors made by residents. MATERIALS AND METHODS: This is a nested retrospective cohort study at a surgery department in an academic medical center...
May 15, 2017: Journal of Surgical Research
https://www.readbyqxmd.com/read/28550911/impact-of-the-introduction-of-electronic-prescribing-on-staff-perceptions-of-patient-safety-and-organizational-culture
#8
James Davies, Philip H Pucher, Heba Ibrahim, Ben Stubbs
BACKGROUND: Electronic prescribing (EP) systems are online technology platforms by which medicines can be prescribed, administered, and stock controlled. The actual impact of EP on patient safety is not truly understood. This study seeks to assess the impact of the implementation of an EP system on safety culture, as well as assessing differences between clinical respondent groups and considering their implications. METHODS: Staff completed a modified Safety Attitudes Questionnaire survey, 6 weeks following the introduction of EP across surgical services in a hospital in Dorset, England...
May 15, 2017: Journal of Surgical Research
https://www.readbyqxmd.com/read/28549789/systematic-approaches-to-adverse-events-in-obstetrics-part-i-event-identification-and-classification
#9
Christian M Pettker
Despite our best intentions to improve health when a patient presents for care, adverse events are ubiquitous in medical practice today. Known complications related to the course of a patient's illness or condition or to the characteristics of the treatment have been an openly stated part of taking care of patients for centuries. However, it is only in the past decade that preventable adverse events, instances of harm related to error and deviations in accepted practice have become a primary part of these conversations...
April 2017: Seminars in Perinatology
https://www.readbyqxmd.com/read/28484690/subcutaneous-and-sublingual-immunotherapy-in-allergic-asthma-in-children
#10
REVIEW
Sophia Tsabouri, Antigoni Mavroudi, Gavriela Feketea, George V Guibas
This review presents up-to-date understanding of immunotherapy in the treatment of children with allergic asthma. The principal types of allergen immunotherapy (AIT) are subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). Both of them are indicated for patients with allergic rhinitis and/or asthma, who have evidence of clinically relevant allergen-specific IgE, and significant symptoms despite reasonable avoidance measures and/or maximal medical therapy. Studies have shown a significant decrease in asthma symptom scores and in the use of rescue medication, and a preventive effect on asthma onset...
2017: Frontiers in Pediatrics
https://www.readbyqxmd.com/read/28484587/reducing-error-in-anticoagulant-dosing-via-multidisciplinary-team-rounding-at-point-of-care
#11
Munish Sharma, Mahesh Krishnamurthy, Richard Snyder, James Mauro
The incorporation of a clinical pharmacist in daily rounding can help identify and correct errors related to anticoagulation dosing. Inappropriate anticoagulant dosing increases the risk of developing significant bleeding diathesis. Conversely, inappropriate dosing may also fail to produce a therapeutic response. We retrospectively reviewed electronic medical records of 41 patients to confirm and analyze the errors related to various anticoagulants. A clinical pharmacist in an integrated rounding between the period of February 2016 and April 2016 collected this data...
April 6, 2017: Clinics and Practice
https://www.readbyqxmd.com/read/28446646/randomized-controlled-trial-of-deutetrabenazine-for-tardive-dyskinesia-the-arm-td-study
#12
RANDOMIZED CONTROLLED TRIAL
Hubert H Fernandez, Stewart A Factor, Robert A Hauser, Joohi Jimenez-Shahed, William G Ondo, L Fredrik Jarskog, Herbert Y Meltzer, Scott W Woods, Danny Bega, Mark S LeDoux, David R Shprecher, Charles Davis, Mat D Davis, David Stamler, Karen E Anderson
OBJECTIVE: To determine the efficacy and safety of deutetrabenazine as a treatment for tardive dyskinesia (TD). METHODS: One hundred seventeen patients with moderate to severe TD received deutetrabenazine or placebo in this randomized, double-blind, multicenter trial. Eligibility criteria included an Abnormal Involuntary Movement Scale (AIMS) score of ≥6 assessed by blinded central video rating, stable psychiatric illness, and stable psychoactive medication treatment...
May 23, 2017: Neurology
https://www.readbyqxmd.com/read/28437546/root-cause-analysis-and-actions-for-the-prevention-of-medical-errors-quality-improvement-and-resident-education
#13
Ryan Charles, Brandon Hood, Joseph M DeRosier, John W Gosbee, James P Bagian, Ying Li, Michelle S Caird, J Sybil Biermann, Mark E Hake
The quality of care delivered by orthopedic surgeons continues to grow in importance. Multiple orthopedic programs, organizations, and committees have been created to measure the quality of surgical care and reduce the incidence of medical adverse events. Structured root cause analysis and actions (RCA2) has become an area of interest. If performed thoroughly, RCA2 has been shown to reduce surgical errors across many subspecialties. The Accreditation Council for Graduate Medical Education has a new mandate for programs to involve residents in quality improvement processes...
July 1, 2017: Orthopedics
https://www.readbyqxmd.com/read/28436158/collaborating-on-medication-errors-in-nursing
#14
Marketa Marvanova, Paul J Henkel
BACKGROUND: Nurse educators are faced with changing roles and expanding responsibilities for medication administration and monitoring in pursuit of improved patient safety. The aims of this study were to develop, implement and evaluate clinical simulation experiences that included, along with nursing faculty members, a pharmacist educator for the teaching of preventable medication errors in undergraduate nursing education. METHODS: Four clinical simulation scenarios using high-fidelity patient simulators were developed focusing on select medication problems in nursing practice...
April 24, 2017: Clinical Teacher
https://www.readbyqxmd.com/read/28417463/pharmacological-interventions-for-primary-sclerosing-cholangitis-an-attempted-network-meta-analysis
#15
REVIEW
Francesca Saffioti, Kurinchi Selvan Gurusamy, Neil Hawkins, Clare D Toon, Emmanuel Tsochatzis, Brian R Davidson, Douglas Thorburn
BACKGROUND: Primary sclerosing cholangitis is a chronic cholestatic liver disease that is associated with both hepatobiliary and colorectal malignancies, which can result in liver cirrhosis and its complications. The optimal pharmacological treatment for patients with primary sclerosing cholangitis remains controversial. OBJECTIVES: To assess the comparative benefits and harms of different pharmacological interventions in people with primary sclerosing cholangitis by performing a network meta-analysis, and to generate rankings of available pharmacological interventions according to their safety and efficacy...
March 28, 2017: Cochrane Database of Systematic Reviews
https://www.readbyqxmd.com/read/28397541/a-novel-patient-safety-event-reporting-tool-in-otolaryngology
#16
Peter M Vila, Sean Lewis, Gene Cunningham, Jean Brereton, Alexandra G Espinel, David W Roberson, Rahul K Shah
Objective To report the results of a preliminary analysis of a quality improvement initiative aimed to identify potential latent systems defects. Methods A pilot study of an anonymous, voluntary, event reporting system made available to all members of the American Academy of Otolaryngology-Head and Neck Surgery was performed. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was used to classify error types. Descriptive statistics were used to summarize submissions to the database...
July 2017: Otolaryngology—Head and Neck Surgery
https://www.readbyqxmd.com/read/28368966/intravenous-administration-errors-intercepted-by-smart-infusion-technology-in-an-adult-intensive-care-unit
#17
Rebecca Ibarra-Pérez, Fabiola Puértolas-Balint, Elizabeth Lozano-Cruz, Sergio E Zamora-Gómez, Lucila I Castro-Pastrana
OBJECTIVES: The aim of the study was to investigate the efficacy of intravenous (IV) smart pumps with drug libraries and dose error reduction system (DERS) to intercept programming errors entailing high risk for patients in an adult intensive care unit (ICU). METHODS: A 2-year retrospective study was conducted in the adult ICU of the Hospital Juárez de México in Mexico City to evaluate the impact of IV smart pump/DERS (Hospira MedNet) technology implementation...
April 1, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28272647/the-impact-of-information-culture-on-patient-safety-outcomes-development-of-a-structural-equation-model
#18
Virpi Jylhä, Santtu Mikkonen, Kaija Saranto, David W Bates
BACKGROUND: An organization's information culture and information management practices create conditions for processing patient information in hospitals. Information management incidents are failures that could lead to adverse events for the patient if they are not detected. OBJECTIVES: To test a theoretical model that links information culture in acute care hospitals to information management incidents and patient safety outcomes. METHODS: Reason's model for the stages of development of organizational accidents was applied...
March 8, 2017: Methods of Information in Medicine
https://www.readbyqxmd.com/read/28259386/proper-management-of-medications-to-limit-errors-what-the-oral-surgeon-should-know-to-limit-medication-errors-and-adverse-drug-events
#19
REVIEW
Daniel S Sarasin, Jarom E Mauer
Providing safe and effective ambulatory anesthesia is a key component in delivering optimal care to oral and maxillofacial patients. Unfortunately, medication errors and adverse drug events (ADEs) occur in offices, as they do in hospital operating rooms. Preparing and delivering medication seems simple. In reality, this is a complex process with multiple opportunities for drug errors leading to actual or potential ADEs. This article reviews medication errors and ADEs, introduces a medication safety paradigm for oral and maxillofacial surgery facilities, and provides practical safety initiatives that can be implemented to achieve the goal of optimal anesthesia patient care and safety...
March 1, 2017: Oral and Maxillofacial Surgery Clinics of North America
https://www.readbyqxmd.com/read/28248748/informing-the-design-of-a-new-pragmatic-registry-to-stimulate-near-miss-reporting-in-ambulatory-care
#20
Elizabeth R Pfoh, Lilly Engineer, Hardeep Singh, Laura Lee Hall, Ethan D Fried, Zackary Berger, Albert W Wu
OBJECTIVE: Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents...
February 28, 2017: Journal of Patient Safety
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