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Patient Safety, Adverse Events, Medical Error

Johannes Erhardt, Erwin Fuhrer, Oliver G Gruschke, Jochen Leupold, Matthias C Wapler, Jurgen Hennig, Thomas Stieglitz, Jan G Korvink
Patients suffering from neuronal degenerative diseases are increasingly being equipped with neural implants to treat symptoms or restore functions and increase their quality of life. Magnetic resonance imaging (MRI) would be the modality of choice for diagnosis and compulsory post-operative monitoring of such patients. However, interactions between the MR environment and implants pose severe health risks to the patient. Nevertheless, neural implant recipients regularly underwent MRI examinations, and adverse events were reported rarely...
March 7, 2018: Journal of Neural Engineering
James N Fleming, Frank Treiber, John McGillicuddy, Mulugeta Gebregziabher, David J Taber
BACKGROUND: Medication errors, adverse drug events, and nonadherence are the predominant causes of graft loss in kidney transplant recipients and lead to increased healthcare utilization. Research has demonstrated that clinical pharmacists have the unique education and training to identify these events early and develop strategies to mitigate or prevent downstream sequelae. In addition, studies utilizing mHealth interventions have demonstrated success in improving the control of chronic conditions that lead to kidney transplant deterioration...
March 2, 2018: JMIR Research Protocols
Carmen Tereanu, Giuseppe Sampietro, Francesco Sarnataro, Dumitru Siscanu, Rodica Palaria, Victor Savin, Tatiana Cliscovscaia, Valentina Pislaru, Valeriu Oglinda, Larisa Capmare, Mugurel Stefan Ghelase, Tamara Turcanu
Background and aims: The Republic of Moldova is a small ex-soviet country in the Central Eastern European group of states, whose official language is Romanian. In countries with limited resources, quality improvement in healthcare and patient safety are very challenging. This study aims to identify which areas of the patient safety culture (PSC) need prompt intervention. Methods: A cross-sectional study was conducted in three Moldovan healthcare settings, using the Romanian translation of the US Hospital Survey on Patient Safety Culture HSOPSC...
2018: Clujul Medical (1957)
Liesbeth B E Bosma, Nicole G M Hunfeld, Rogier A M Quax, Edmé Meuwese, Piet H G J Melief, Jasper van Bommel, SiokSwan Tan, Maaike J van Kranenburg, Patricia M L A van den Bemt
BACKGROUND: Medication errors occur frequently in the intensive care unit (ICU) and during care transitions. Chronic medication is often temporarily stopped at the ICU. Unfortunately, when the patient improves, the restart of this medication is easily forgotten. Moreover, temporal ICU medication is often unintentionally continued after ICU discharge. Medication reconciliation could be useful to prevent such errors. Therefore, the aim of this study was to determine the effect of medication reconciliation at the ICU...
February 7, 2018: Annals of Intensive Care
Megan H Noe, Joel M Gelfand
Clinical trials have several important limitations for evaluating the safety of new medications, leading to many adverse events not being identified until the postmarketing period. Descriptive studies, including case reports, case series, cross-sectional, and ecologic studies, help identify potential safety signals and generate hypotheses. Further research using analytic study methods, including case-control studies and cohort studies, are necessary to determine if an association truly exists and to better understand the potential for causation...
February 2018: Journal of Investigative Dermatology
Yael K Heher, Suzanne M Dintzis
Harmful error is an infrequent but serious challenge in the pathology laboratory. Regulatory bodies and advocacy groups have mandated and encouraged disclosure of error to patients. Many pathologists are interested in participating in disclosure of harmful error but are ill-equipped to do so. This review of the literature with recommendations examines the current state of the patient safety movement and error disclosure as it pertains to pathology and provides a practical and explicit guide for pathologists for who, when, and how to disclose harmful pathology error to patients...
March 2018: Advances in Anatomic Pathology
Ashley C Crimmins, Ambrose H Wong, James W Bonz, Alina Tsyrulnik, Karen Jubanyik, James D Dziura, Kelly L Dodge, Leigh V Evans
INTRODUCTION: Although error disclosure is critical in promoting safety and patient-centered care, physicians are inconsistently trained in its practice, and few objective methods to assess competence exist. We used an immersive simulation scenario to determine whether providers with varying levels of clinical experience adhere to the disclosure safe practice guidelines when exposed to a serious adverse event simulation scenario. METHODS: This was a prospective cohort study with medical students, junior emergency medicine (EM) residents (PGY 1-2), senior EM residents (PGY 3-4), and attending EM physicians participating in a simulated case in which a scripted medication overdose resulted in an adverse event...
January 17, 2018: Simulation in Healthcare: Journal of the Society for Simulation in Healthcare
Joshua Davis, Nicole Harrington, Heather Bittner Fagan, Barbara Henry, Margot Savoy
PURPOSE: To understand the ability of trigger tools to detect preventable adverse events (pAEs) in the primary care outpatient setting using the Institute for Healthcare Improvement's (IHI) Outpatient Adverse Event Trigger Tool (IHI Tool). METHODS: The OVID MEDLINE and OVID MEDLINE In-process and non-Indexed citations databases were queried using controlled vocabulary and Medical Subject Headings related to the concepts "primary care" and "adverse events." Included articles were conducted in the outpatient setting, used at least 1 of the triggers identified in the IHI Tool, and identified pAEs of any type...
January 2018: Journal of the American Board of Family Medicine: JABFM
Géraldine Leguelinel-Blache, Christel Castelli, Clarisse Roux-Marson, Sophie Bouvet, Sandrine Andrieu, Philippe Cestac, Rémy Collomp, Paul Landais, Bertrice Loulière, Christelle Mouchoux, Rémi Varin, Benoit Allenet, Pierrick Bedouch, Jean-Marie Kinowski
BACKGROUND: Clinical pharmaceutical care has long played an important role in the improvement of healthcare safety. Pharmaceutical care is a collaborative care approach, implicating all the actors of the medication circuit in order to prevent and correct drug-related problems that can lead to adverse drug events. The collaborative pharmaceutical care performed during patients' hospitalization requires two mutually reinforcing activities: medication reconciliation and medication review...
January 8, 2018: Trials
A H Abdelhafiz, A J Sinclair
IMPORTANCE: Intensive treatment of older people with diabetes is common placing them at increased risk of adverse events such as hypoglycaemia and hospitalisation for drug errors. Little is known about when, how or for whom to deintensify hypoglycaemic medications. OBJECTIVE: To explore the characteristics of patients for whom deintensification is appropriate and to determine the outcome of deintensification. EVIDENCE REVIEW: Medline, Google scholar and EmBase search from 1997 to present was performed using keywords relating to diabetes mellitus, polypharmacy, hypoglycaemia, hospitalisation, deintensification, deprescribing and reduction, simplification or withdrawal of hypoglycaemic medications...
November 29, 2017: Journal of Diabetes and its Complications
Nazanin Abolhassani, Ali Akbari Sari, Arash Rashidian, Mansoor Rastegarpanah
Background: The recognition of patient safety is now occupying a prominent place on the health policy agenda since medical errors can result in adverse events. The existence of confusing drug names is one of the most common causes of medication errors. In Iran, the General Office of Trademarks Registry (GOTR), for four years (2010-2014) was responsible for approving drug proprietary names. This study aimed to investigate the performance of the GOTR in terms of drug names orthographic similarity using the SOLAR model...
December 2017: Iranian Journal of Public Health
Gudrun Reay, Jill M Norris, K Alix Hayden, Joanna Abraham, Katherine Yokom, Lorelli Nowell, Gerald C Lazarenko, Eddy S Lang
BACKGROUND: Effective and efficient transitions in care between emergency medical services (EMS) practitioners and emergency department (ED) nurses is vital as poor clinical transitions in care may place patients at increased risk for adverse events such as delay in treatment for time sensitive conditions (e.g., myocardial infarction) or worsening of status (e.g., sepsis). Such transitions in care are complex and prone to communication errors primarily caused by misunderstanding related to divergent professional perspectives leading to misunderstandings that are further susceptible to contextual factors and divergent professional lenses...
December 19, 2017: Systematic Reviews
Khulood H Abdulghani, Mohammed A Aseeri, Ahmed Mahmoud, Rayf Abulezz
Background Medication errors represent the most common type of error that compromises patient safety, with approximately 20% believed to result in harm. Over 40% of these errors are believed to result from inadequate medication reconciliation during admission, transfer, and discharge of patients and many of these errors could be prevented if adequate medication reconciliation processes were in place. In an effort to minimize adverse events caused during these care transitions, the Joint Commission has stated medication reconciliation as one of its National Patient Safety Goals and health care providers and organizations are encouraged to perform the process at various patient care transitions...
December 16, 2017: International Journal of Clinical Pharmacy
Alejandro Arrieta, Gabriela Suárez, Galed Hakim
Objective: To assess the patient safety culture in Peruvian hospitals from the perspective of healthcare professionals, and to test for differences between the private and public healthcare sectors. Patient safety is defined as the avoidance and prevention of patient injuries or adverse events resulting from the processes of healthcare delivery. Design: A non-random cross-sectional study conducted online. Setting: An online survey was administered from July to August 2016, in Peru...
December 8, 2017: International Journal for Quality in Health Care
Oluwabunmi Tokede, Muhammad Walji, Rachel Ramoni, Donald B Rindal, Donald Worley, Nutan Hebballi, Krishna Kumar, Claire van Strien, Mengxia Chen, Shaked Navat-Pelli, Hongchun Liu, Jini Etolue, Alfa Yansane, Enihomo Obadan-Udoh, Casey Easterday, Chris Enstad, Sheryl Kane, William Rush, Elsbeth Kalenderian
BACKGROUND: Preventable medical errors in hospital settings are the third leading cause of deaths in the United States. However, less is known about harm that occurs in patients in outpatient settings, where the majority of care is delivered. We do not know the likelihood that a patient sitting in a dentist chair will experience harm. Additionally, we do not know if patients of certain race, age, sex, or socioeconomic status disproportionately experience iatrogenic harm. METHODS: We initiated the Dental Practice Study (DPS) with the aim of determining the frequency and types of adverse events (AEs) that occur in dentistry on the basis of retrospective chart audit...
December 5, 2017: Journal of Patient Safety
Karen L Weihs, William Murphy, Richat Abbas, Deborah Chiles, Richard D England, Sara Ramaker, Dalia B Wajsbrot
OBJECTIVES: To evaluate the short-term efficacy and safety of desvenlafaxine (25-50 mg/d) compared with placebo in children and adolescents with major depressive disorder (MDD). METHODS: Outpatient children (7-11 years) and adolescents (12-17 years) who met DSM-IV-TR criteria for MDD and had screening and baseline Children's Depression Rating Scale-Revised (CDRS-R) total scores >40 were randomly assigned to 8-week treatment with placebo, desvenlafaxine (25, 35, or 50 mg/d based on baseline weight), or fluoxetine (20 mg/d)...
February 2018: Journal of Child and Adolescent Psychopharmacology
Per Winkel, Philip M Bath, Christian Gluud, Jane Lindschou, H Bart van der Worp, Malcolm R Macleod, Istvan Szabo, Isabelle Durand-Zaleski, Stefan Schwab
BACKGROUND: Cooling may reduce infarct size and improve neurological outcomes in patients with ischaemic stroke. In phase II trials, cooling awake patients with ischaemic stroke has been shown to be feasible and safe, but the effects in functional outcomes has not yet been investigated in an adequately sized randomised clinical trial. METHODS/DESIGN: The EuroHYP-1 trial is a multinational, randomised, superiority phase III clinical trial with masked outcome assessment testing the benefits and harms of therapeutic cooling in awake adult patients with acute ischaemic stroke...
November 29, 2017: Trials
María Mercedes Guerra-García, Beatriz Campos-Rivas, Alexandra Sanmarful-Schwarz, Alicia Vírseda-Sacristán, M Aránzazu Dorrego-López, Ángeles Charle-Crespo
OBJECTIVE: To assess the extent of healthcare related adverse events (AEs), their effect on patients, and their seriousness. To analyse the factors leading to the development of AEs, their relationship with the damage caused, and their degree of preventability. DESIGN: Retrospective descriptive study. LOCATION: Porriño, Pontevedra, Spain, Primary Care Service, from January-2014 to April-2016. PARTICIPANTS AND/OR CONTEXT: Reported AEs were entered into the Patient Safety Reporting and Learning System (SiNASP)...
November 25, 2017: Atencion Primaria
Markus Latzke, Michael Schiffinger, Dominik Zellhofer, Johannes Steyrer
BACKGROUND: Intrahospital patient transports (IHTs) in intensive care involve an appreciable risk of adverse events (AEs). Research on determinants of AE occurrence during IHT has hitherto focused on patient, transport, and intensive care unit (ICU) characteristics. By contrast, the role of "soft" factors, although arguably relevant for IHTs and a topic of interest in general health care settings, has not yet been explored. PURPOSE: The study aims at examining the effect of safety climate and team processes on the occurrence of AE during IHT and whether team processes mediate the effect of safety climate...
November 15, 2017: Health Care Management Review
Sreedhar Sagi, Hillel P Cohen, Gillian R Woollett
It is important that systems are in place to ensure that appropriate and comprehensive records are kept for use of all medications. It is fundamental to an effective pharmacovigilance system that patient medical records contain sufficient information to identify which medication has been prescribed, when it was administered, and at what dose. The availability of biologics from multiple sponsors has raised questions by some health care providers about the ability of current pharmacovigilance systems to trace specific biologics...
December 2017: Journal of Managed Care & Specialty Pharmacy
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