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Patient Safety, Adverse Events, Medical Error

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
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
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
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
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
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
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
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
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
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
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
Marie-Sophie Grave, Fritz Sterz, Alexander Nürnberger, Stergios Fykatas, Mathias Gatterbauer, Albert Friedrich Stättermayer, Andreas Zajicek, Reinhard Malzer, Dieter Sebald, Raphael van Tulder
We investigated feasibility and safety of the RhinoChill (RC) transnasal cooling system initiated before achieving a protected airway during cardiopulmonary resuscitation (CPR) in a prehospital setting.In out-of-hospital cardiac arrest (OHCA), transnasal evaporative cooling was initiated during CPR, before a protected airway was established and continued until either the patient was declared dead, standard institutional systemic cooling methods were implemented or cooling supply was empty. Patients were monitored throughout the hypothermia period until either death or hospital discharge...
August 2016: Medicine (Baltimore)
Andrea L Benin, Samah Jamal Fodeh, Kyle Lee, Michele Koss, Perry Miller, Cynthia Brandt
INTRODUCTION: Health care organizations working to eliminate preventable harm and to improve patient safety must have robust programs to collect and to analyze data on adverse events in order to use the information to affect improvement. Such adverse event reporting systems are based on frontline personnel reporting issues that arise in the course of their daily work. Limitations in how existing software systems handle these reports mean that use of this potentially rich information is resource intensive and prone to variable results...
August 2016: Journal of Healthcare Risk Management: the Journal of the American Society for Healthcare Risk Management
Eric S Kirkendall, Michal Kouril, Judith W Dexheimer, Joshua D Courter, Philip Hagedorn, Rhonda Szczesniak, Dan Li, Rahul Damania, Thomas Minich, S Andrew Spooner
OBJECTIVES: Electronic trigger detection tools hold promise to reduce Adverse drug event (ADEs) through efficiencies of scale and real-time reporting. We hypothesized that such a tool could automatically detect medication dosing errors as well as manage and evaluate dosing rule modifications. MATERIALS AND METHODS: We created an order and alert analysis system that identified antibiotic medication orders and evaluated user response to dosing alerts. Orders associated with overridden alerts were examined for evidence of administration and the delivered dose was compared to pharmacy-derived dosing rules to confirm true overdoses...
August 9, 2016: Journal of the American Medical Informatics Association: JAMIA
Gaia Kiru, Colin Bicknell, Emanuela Falaschetti, Janet Powell, Neil Poulter
BACKGROUND: Although data are inconsistent, angiotensin-converting enzyme inhibitors (ACE-Is) have been associated with a reduced incidence of abdominal aortic aneurysm (AAA) rupture in analysis of administrative databases. OBJECTIVES: (1) To investigate whether or not the ACE-I perindopril (Coversyl arginine, Servier) reduces small AAA growth rate and (2) to evaluate blood pressure (BP)-independent effects of perindopril on small AAA growth and to compare the repeatability of measurement of internal and external aneurysm diameters...
July 2016: Health Technology Assessment: HTA
Edwin N Aroke, Jennifer R Dungan
BACKGROUND: Monitoring a patient's response to drug therapy and early identification of an adverse reaction are important responsibilities of nurses. Despite the relative safety of anesthesia practice, 1 in 20 perioperative medication administrations includes a medication error and/or adverse drug reaction. Although several factors contribute to an individual's response to medications, genetic predisposition accounts for over 50% of that response. OBJECTIVE: The purpose of this review is to explore the evidence of genetic variability associated with response to volatile and intravenous anesthetics...
July 2016: Nursing Research
Jo Shapiro, Pamela Galowitz
Burnout is plaguing the culture of medicine and is linked to several primary causes including long work hours, increasingly burdensome documentation, and resource constraints. Beyond these, additional emotional stressors for physicians are involvement in an adverse event, especially one that involves a medical error, and malpractice litigation. The authors argue that it is imperative that health care institutions devote resources to programs that support physician well-being and resilience. Doing so after adverse and other emotionally stressful events, such as the death of a colleague or caring for victims of a mass trauma, is crucial as clinicians are often at their most vulnerable during such times...
September 2016: Academic Medicine: Journal of the Association of American Medical Colleges
Erin Truitt, Ross Thompson, Deborah Blazey-Martin, Danna NiSai, Deeb Salem
BACKGROUND: Hospitals have attempted to reduce adverse drug events (ADEs) by investing in new technologies, but data regarding their efficacy are lacking. OBJECTIVES: This study evaluates the effects of the implementation of barcode medication administration (BCMA) and electronic medication administration record (eMAR) technology on the profile of ADEs in a hospital setting. METHODS: We conducted a before-and-after study examining the effects of the implementation of BCMA and eMAR technology on the profile of ADEs at a 400-bed academic medical center by using incident reports...
June 2016: Hospital Pharmacy
Eunjoo Lee
OBJECTIVE: This study compared registered nurses' perceptions of safety climate and attitude toward medication error reporting before and after completing a hospital accreditation program. Medication errors are the most prevalent adverse events threatening patient safety; reducing underreporting of medication errors significantly improves patient safety. Safety climate in hospitals may affect medication error reporting. DESIGN: This study employed a longitudinal, descriptive design...
September 2016: International Journal for Quality in Health Care
Alison Thomas, Samuel A Silver, Andrea Rathe, Pamela Robinson, Ron Wald, Chaim M Bell, Ziv Harel
BACKGROUND: Patients with end-stage renal disease are at high risk for medical errors given their comorbidities, polypharmacy and coordination of care with other hospital departments. We previously developed a hemodialysis safety checklist (Hemo Pause) to be jointly completed by nurses and patients. Our objective was to determine the feasibility of using this checklist during every hemodialysis session for 3 months. METHODS: We conducted a single-center, prospective time series study...
June 2016: Clinical Kidney Journal
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