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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/27919281/incidence-causes-and-consequences-of-preventable-adverse-drug-events-protocol-for-an-overview-of-reviews
#1
Brian Hutton, Salmaan Kanji, Erika McDonald, Fatemeh Yazdi, Dianna Wolfe, Kednapa Thavorn, Sally Pepper, Laurie Chapman, Becky Skidmore, David Moher
BACKGROUND: Medication errors represent a noteworthy source of harm to patients. In recent years, several systematic reviews have assessed the frequency and causes of these events, as well as other factors such as commonly associated drugs, their incidence in different specialties, and their consequences to patients. Despite this past literature, there remains a need to study discrepancies between these reviews and establish the current state of the evidence. The planned review will bring together, compare, and contract existing evidence related to the occurrence of medication errors in acute and continuing/long-term care settings...
December 5, 2016: Systematic Reviews
https://www.readbyqxmd.com/read/27915360/patient-safety-organizations-and-emergency-medical-services
#2
William J Leggio, Lee Varner, Kathryn Wire
Providing safe and error-free patient care should resonate well with all healthcare providers including emergency medical technicians. The environments and circumstances in which emergency medical services (EMS) provide patient care inevitably create risks to both the provider and patient. This article explores the concepts of patient safety, errors, near misses, adverse events, and Just Culture. Literature raises concerns about the lack of data collection on both patient and provider safety and research on these safety topics in EMS...
2016: Journal of Allied Health
https://www.readbyqxmd.com/read/27896144/clinical-decision-support-for-drug-related-events-moving-towards-better-prevention
#3
REVIEW
Sandra L Kane-Gill, Archita Achanta, John A Kellum, Steven M Handler
Clinical decision support (CDS) systems with automated alerts integrated into electronic medical records demonstrate efficacy for detecting medication errors (ME) and adverse drug events (ADEs). Critically ill patients are at increased risk for ME, ADEs and serious negative outcomes related to these events. Capitalizing on CDS to detect ME and prevent adverse drug related events has the potential to improve patient outcomes. The key to an effective medication safety surveillance system incorporating CDS is advancing the signals for alerts by using trajectory analyses to predict clinical events, instead of waiting for these events to occur...
November 4, 2016: World Journal of Critical Care Medicine
https://www.readbyqxmd.com/read/27884844/medication-reconciliation-as-a-medication-safety-initiative-in-ethiopia-a-study-protocol
#4
Alemayehu B Mekonnen, Andrew J McLachlan, Jo-Anne E Brien, Desalew Mekonnen, Zenahebezu Abay
INTRODUCTION: Medication related adverse events are common, particularly during transitions of care, and have a significant impact on patient outcomes and healthcare costs. Medication reconciliation (MedRec) is an important initiative to achieve the Quality Use of Medicines, and has been adopted as a standard practice in many developed countries. However, the impact of this strategy is rarely described in Ethiopia. The aims of this study are to explore patient safety culture, and to develop, implement and evaluate a theory informed MedRec intervention, with the aim of minimising the incidence of medication errors during hospital admission...
November 24, 2016: BMJ Open
https://www.readbyqxmd.com/read/27872173/medical-morbidity-and-mortality-conferences-past-present-and-future
#5
REVIEW
J George
Morbidity and mortality conferences (MMCs) have three potential aims-to improve patient safety by reducing adverse events and preventable deaths, to improve overall quality of care as part of the hospital governance structure and as educational learning events. At present, medical MMCs vary widely in format and attendance from hospital to hospital. The evidence for MMCs actually reducing adverse events and preventing avoidable deaths is disappointing. There is better evidence for their educational role. The majority of medical deaths in hospitals are frail older people with poor life expectancy in whom inadequate care is more likely to be due to errors of omission rather than commission...
November 21, 2016: Postgraduate Medical Journal
https://www.readbyqxmd.com/read/27811598/a-patient-reported-approach-to-identify-medical-errors-and-improve-patient-safety-in-the-emergency-department
#6
Seth W Glickman, Abhi Mehrotra, Christopher M Shea, Celeste Mayer, Jeffrey Strickler, Sandra Pabers, James Larson, Brian Goldstein, Larry Mandelkehr, Charles B Cairns, Jesse M Pines, Kevin A Schulman
OBJECTIVE: Medical errors in the emergency department (ED) occur frequently. Yet, common adverse event detection methods, such as voluntary reporting, miss 90% of adverse events. Our objective was to demonstrate the use of patient-reported data in the ED to assess patient safety, including medical errors. METHODS: Analysis of patient-reported survey data collected over a 1-year period in a large, academic emergency department. All patients who provided a valid e-mail or cell phone number received a brief electronic survey within 24 hours of their ED encounter by e-mail or text message with Web link...
November 2, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27779820/provider-perspectives-on-safety-in-primary-care-in-albania
#7
Jonila Cyco Gabrani, Wendy Knibb, Elizana Petrela, Adrian Hoxha, Adriatik Gabrani
PURPOSE: The purpose of this study was to determine the safety attitudes of specialist physicians (SPs), general physicians (GPs), and nurses in primary care in Albania. DESIGN: The study was cross-sectional. It involved the SPs, GPs, and nurses from five districts in Albania. A demographic questionnaire and the adapted Safety Attitudes Questionnaire (SAQ)-Long Ambulatory Version A was used to gather critical information regarding the participant's profile, perception of management, working conditions, job satisfaction, stress recognition, safety climate, and perceived teamwork...
October 25, 2016: Journal of Nursing Scholarship
https://www.readbyqxmd.com/read/27775303/-implementation-of-a-plan-of-patient-safety-in-service-of-pediatric-surgery-first-results
#8
R M Paredes Esteban, J I Garrido Pérez, A Ruiz Palomino, G Guerrero Peña, F Vázquez Rueda, M J Berenguer García, R Miñarro Del Moral, M Tejedor Fernández
OBJECTIVES: In 2014 our department starts to apply the PatientSafety Strategic in Pediatric Surgery. Our aim is to describe the results obtained. METHODS: For the measurement of adverse events (AE) we used a modification of the Global Trigger Tool of the Institute for Healthcare Improvement. Population analysed: patients undergoing surgery with hospitalization. On a monthly basis, audits of the medical records of 12 patients discharged in the prior week of the assessment were performed...
July 20, 2015: Cirugía Pediátrica: Organo Oficial de la Sociedad Española de Cirugía Pediátrica
https://www.readbyqxmd.com/read/27768654/measuring-patient-safety-the-medicare-patient-safety-monitoring-system-past-present-and-future
#9
David C Classen, William Munier, Nancy Verzier, Noel Eldridge, David Hunt, Mark Metersky, Chesley Richards, Yun Wang, P Jeffrey Brady, Amy Helwig, James Battles
The explicit declaration in the landmark 1999 Institute of Medicine report "To Err Is Human" that, in the United States, 44,000 to 98,000 patients die each year as a consequence of "medical errors" gave widespread validation to the magnitude of the patient safety problem and catalyzed a number of U.S. federal government programs to measure and improve the safety of the national healthcare system. After more than 10 years, one of those federal programs, the Medicare Patient Safety Monitoring System (MPSMS), has reached a level of maturity and stability that has made it useful for the consistent measurement of the safety of inpatient care...
October 20, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27733666/the-impacts-of-a-pharmacist-managed-outpatient-clinic-and-chemotherapy-directed-electronic-order-sets-for-monitoring-oral-chemotherapy
#10
Brandon Battis, Linda Clifford, Mostaqul Huq, Edrick Pejoro, Scott Mambourg
OBJECTIVES: Patients treated with oral chemotherapy appear to have less contact with the treating providers. As a result, safety, adherence, medication therapy monitoring, and timely follow-up may be compromised. The trend of treating cancer with oral chemotherapy agents is on the rise. However, standard clinical guidance is still lacking for prescribing, monitoring, patient education, and follow-up of patients on oral chemotherapy across the healthcare settings. The purpose of this project is to establish an oral chemotherapy monitoring clinic, to create drug and lab specific provider order sets for prescribing and lab monitoring, and ultimately to ensure safe and effective treatment of the veterans we serve...
October 12, 2016: Journal of Oncology Pharmacy Practice
https://www.readbyqxmd.com/read/27715352/advancing-interprofessional-patient-safety-education-for-medical-nursing-and-pharmacy-learners-during-clinical-rotations
#11
Kerri A Thom, Emily L Heil, Lindsay D Croft, Alison Duffy, Daniel J Morgan, Mary Johantgen
Clinical errors are common and can lead to adverse events and patient death. Health professionals must work within interprofessional teams to provide safe and effective care to patients, yet current curricula is lacking with regards to interprofessional education and patient safety. We describe the development and implementation of an interprofessional course aimed at medical, nursing, and pharmacy learners during their clinical training at a large academic medical centre. The course objectives were based on core competencies for interprofessional education and patient safety...
August 11, 2016: Journal of Interprofessional Care
https://www.readbyqxmd.com/read/27703622/a-first-step-toward-understanding-patient-safety
#12
Kyoung Ok Kim
Patient safety has become an important policy agenda in healthcare systems since publication of the 1999 report entitled "To Err Is Human." The paradigm has changed from blaming the individual for the error to identifying the weakness in the system that led to the adverse events. Anesthesia is one of the first healthcare specialties to adopt techniques and lessons from the aviation industry. The widespread use of simulation programs and the application of human factors engineering to clinical practice are the influences of the aviation industry...
October 2016: Korean Journal of Anesthesiology
https://www.readbyqxmd.com/read/27680056/nursing-workload-and-occurrence-of-adverse-events-in-intensive-care-a-systematic-review
#13
Andrea Carvalho de Oliveira, Paulo Carlos Garcia, Lilia de Souza Nogueira
OBJECTIVE: To identifyevidences of the influence of nursing workload on the occurrence of adverse events (AE) in adult patients admitted to the intensive care unit (ICU). METHOD: A systematic literature review was conducted in the databases MEDLINE, CINAHL, LILACS, SciELO, BDENF, and Cochrane from studies in English, Portuguese, or Spanish, published by 2015. The analyzed AE were infection, pressure ulcer (PU), patient falls, and medication errors. RESULTS: Of 594 potential studies, eight comprised the final sample of the review...
July 2016: Revista da Escola de Enfermagem da U S P
https://www.readbyqxmd.com/read/27648959/adverse-safety-events-in-patients-with-chronic-kidney-disease-ckd
#14
Ada Offurum, Lee-Ann Wagner, Tanisha Gooden
Chronic kidney disease (CKD) confers a higher risk of adverse safety events as a result of many factors including medication dosing errors and use of nephrotoxic drugs, which can cause kidney injury and renal function decline. CKD patients may also have comorbidities such as hypertension and diabetes for which they require more frequent care from different providers, and for which standard, but countervailing treatments, may put them at risk for adverse safety events. Areas covered: In addition to the well-known agents such as iodinated radiocontrast, antimicrobials, diuretics and angiotensin converting enzyme (ACE) inhibitors which can directly affect renal function, safety considerations in the treatment of common CKD complications such as anemia, diabetes, analgesia and thrombosis will also be discussed...
October 12, 2016: Expert Opinion on Drug Safety
https://www.readbyqxmd.com/read/27623822/patient-safety-in-otolaryngology-a-descriptive-review
#15
Julian Danino, Jameel Muzaffar, Chris Metcalfe, Chris Coulson
Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published...
September 13, 2016: European Archives of Oto-rhino-laryngology
https://www.readbyqxmd.com/read/27618825/efficacy-and-safety-of-alirocumab-in-patients-with-heterozygous-familial-hypercholesterolemia-and-ldl-c-of-160%C3%A2-mg-dl-or-higher
#16
Henry N Ginsberg, Daniel J Rader, Frederick J Raal, John R Guyton, Marie T Baccara-Dinet, Christelle Lorenzato, Robert Pordy, Erik Stroes
PURPOSE: Even with statins and other lipid-lowering therapy (LLT), many patients with heterozygous familial hypercholesterolemia (heFH) continue to have elevated low-density lipoprotein cholesterol (LDL-C) levels. ODYSSEY HIGH FH (NCT01617655) assessed the efficacy and safety of alirocumab, a proprotein convertase subtilisin/kexin type 9 monoclonal antibody, versus placebo in patients with heFH and LDL-C ≥ 160 mg/dl despite maximally tolerated statin ± other LLT. METHODS: Patients were randomized to subcutaneous alirocumab 150 mg or placebo every 2 weeks (Q2W) for 78 weeks...
October 2016: Cardiovascular Drugs and Therapy
https://www.readbyqxmd.com/read/27609720/the-alarming-reality-of-medication-error-a-patient-case-and-review-of-pennsylvania-and-national-data
#17
Brianna A da Silva, Mahesh Krishnamurthy
CASE DESCRIPTION: A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. DISCUSSION: Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up...
2016: Journal of Community Hospital Internal Medicine Perspectives
https://www.readbyqxmd.com/read/27601424/collaboration-with-regulators-to-support-quality-and-accountability-following-medical-errors-the-communication-and-resolution-program-certification-pilot
#18
Thomas H Gallagher, Michael L Farrell, Hannah Karson, Sarah J Armstrong, John T Maldon, Michelle M Mello, Bruce F Cullen
OBJECTIVE: Communication and resolution programs (CRPs) involve institutions responding to adverse events using transparency with patients, event analysis, recurrence prevention, and compensation. Collaboration with regulators around CRPs could enhance health care quality. SETTING AND PARTICIPANTS: Health care institutions, liability insurers, and the Medical Quality Assurance Commission (MQAC, board of medicine) in Washington State. STUDY DESIGN: MQAC has collaborated with the Foundation for Health Care Quality (FHCQ) on the CRP Certification pilot...
September 7, 2016: Health Services Research
https://www.readbyqxmd.com/read/27574399/efficacy-and-safety-of-fixed-dose-combination-therapy-with-olmesartan-medoxomil-and-rosuvastatin-in-korean-patients-with-mild-to-moderate-hypertension-and-dyslipidemia-an-8-week-multicenter-randomized-double-blind-factorial-design-study-olsta-d-rct-olmesartan
#19
Jin-Sun Park, Joon-Han Shin, Taek-Jong Hong, Hong-Seog Seo, Wan-Joo Shim, Sang-Hong Baek, Jin-Ok Jeong, Youngkeun Ahn, Woong-Chol Kang, Young-Hak Kim, Sang-Hyun Kim, Min-Su Hyon, Dong-Hoon Choi, Chang-Wook Nam, Tae-Ho Park, Sang-Chol Lee, Hyo-Soo Kim
The pill burden of patients with hypertension and dyslipidemia can result in poor medication compliance. This study aimed to evaluate the efficacy and safety of fixed-dose combination (FDC) therapy with olmesartan medoxomil (40 mg) and rosuvastatin (20 mg) in Korean patients with mild to moderate hypertension and dyslipidemia. This multicenter, randomized, double-blind, factorial-design study included patients aged ≥20 years with mild to moderate essential hypertension and dyslipidemia. Patients were randomly assigned to receive FDC therapy (40 mg olmesartan medoxomil, 20 mg rosuvastatin), 40 mg olmesartan medoxomil, 20 mg rosuvastatin, or a placebo...
2016: Drug Design, Development and Therapy
https://www.readbyqxmd.com/read/27567765/medication-errors-among-health-professionals-in-nigeria-a-national-survey
#20
Olayinka O Ogunleye, Ibrahim A Oreagba, Catherine Falade, Ambrose Isah, Okezie Enwere, Sunday Olayemi, Sunday O Ogundele, Reginald Obiako, Rachel Odesanya, Peter Bassi, John Obodo, Jelili Kilani, Mathew Ekoja
BACKGROUND: Medication errors are preventable causes of patient harm with significant contributions to adverse drug events but they remain understudied in Nigeria. OBJECTIVES: To estimate the prevalence of self-reported medication errors among health professionals and examine their knowledge of medication errors with the hope of identifying appropriate measures to promote medication safety. METHODS: A cross sectional survey among doctors, pharmacists and nurses in 10 tertiary hospitals...
August 22, 2016: International Journal of Risk & Safety in Medicine
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