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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/28103397/the-economic-burden-of-nurse-sensitive-adverse-events-in-22-medical-surgical-units-retrospective-and-matching-analysis
#1
Eric Tchouaket, Carl-Ardy Dubois, Danielle D'Amour
AIMS: To assess the economic burden of nurse-sensitive adverse events (NSAEs) in 22 acute care units in Quebec by estimating excess hospital-related costs and calculating resulting additional hospital days. BACKGROUND: Recent changes in the worldwide economic and financial contexts have made the cost of patient safety a topical issue. Yet our knowledge about the economic burden of safety of nursing care is quite limited in Canada in general and Quebec in particular...
January 19, 2017: Journal of Advanced Nursing
https://www.readbyqxmd.com/read/28099789/ehr-related-medication-errors-in-two-icus
#2
Pascale Carayon, Shimeng Du, Roger Brown, Randi Cartmill, Mark Johnson, Tosha B Wetterneck
The objective of this study was to describe the frequency, potential harm, and nature of electronic health record (EHR)-related medication errors in intensive care units (ICUs). Using a secondary data analysis of a large database of medication safety events collected in a study on EHR technology in ICUs, we assessed the EHR relatedness of a total of 1622 potential preventable adverse drug events (ADEs) identified in a sample of 624 patients in 2 ICUs of a medical center. Thirty-four percent of the medication events were found to be EHR related...
January 2017: Journal of Healthcare Risk Management: the Journal of the American Society for Healthcare Risk Management
https://www.readbyqxmd.com/read/28098743/analysis-of-incident-and-accident-reports-and-risk-management-in-spine-surgery
#3
Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Tetsuro Hida, Kenyu Ito, Mikito Tsushima, Yoshimoto Ishikawa, Akiyuki Matsumoto, Masayoshi Morozumi, Yoshihiro Nishida, Yoshimasa Nagao, Naoki Ishiguro
STUDY DESIGN: A review of accident and incident reports. OBJECTIVE: To analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery. SUMMARY OF BACKGROUND DATA: In our institution, a clinical error that potentially results in an adverse event is usually submitted as an incident or accident report through a web database, to ensure anonymous and blame-free reporting. All reports are analyzed by a medical safety management group...
January 16, 2017: Spine
https://www.readbyqxmd.com/read/28076342/knowledge-beliefs-and-attitudes-report-on-patient-care-and-safety-in-undergraduate-students-validating-the-modified-apsq-iii-questionnaire
#4
Ezequiel García Elorrio, Dolores Macchiavello, Viviana Rodriguez, Yael Catalano, Giuliana Corna, Josefina Dahinten, Marina Ontivero
INTRODUCTION: Patient safety aims to achieve healthcare free of damage. The World Health Organization indicates that this objective is achieved through communication, analysis, and prevention of adverse events in patients. Organizational culture has been identified as one of the main factors for interventions aimed to reduce medical errors; and an essential component of safety culture is the attitude of health professionals towards medical error. Attitudes can be improved through appropriate education in biomedical careers but its inclusion in Argentina is scarce...
December 20, 2016: Medwave
https://www.readbyqxmd.com/read/28069072/pansaid-paracetamol-and-nsaid-in-combination-study-protocol-for-a-randomised-trial
#5
Kasper Højgaard Thybo, Daniel Hägi-Pedersen, Jørn Wetterslev, Jørgen Berg Dahl, Henrik Morville Schrøder, Hans Henrik Bülow, Jan Gottfrid Bjørck, Ole Mathiesen
BACKGROUND: Effective postoperative pain management is essential for the rehabilitation of the surgical patient. No 'gold standard' exists after total hip arthroplasty (THA) and combinations of different nonopioid medications are used with virtually no evidence for additional analgesic efficacy compared to monotherapy. The objective of this trial is to investigate the analgesic effects and safety of paracetamol and ibuprofen alone and in combination in different dosages after THA. METHODS: PANSAID is a placebo-controlled, parallel four-group, multicentre trial with centralised computer-generated allocation sequence and allocation concealment and with varying block size and stratification by site...
January 10, 2017: Trials
https://www.readbyqxmd.com/read/28063462/going-digital-a-narrative-overview-of-the-clinical-and-organisational-impacts-of-ehealth-technologies-in-hospital-practice
#6
Justin Keasberry, Ian A Scott, Clair Sullivan, Andrew Staib, Richard Ashby
Objective The aim of the present study was to determine the effects of hospital-based eHealth technologies on quality, safety and efficiency of care and clinical outcomes.Methods Systematic reviews and reviews of systematic reviews of eHealth technologies published in PubMed/Medline/Cochrane Library between January 2010 and October 2015 were evaluated. Reviews of implementation issues, non-hospital settings or remote care or patient-focused technologies were excluded from analysis. Methodological quality was assessed using a validated appraisal tool...
January 9, 2017: Australian Health Review: a Publication of the Australian Hospital Association
https://www.readbyqxmd.com/read/28039240/medication-safety-in-the-operating-room-literature-and-expert-based-recommendations
#7
J A Wahr, J H Abernathy, E H Lazarra, J R Keebler, M H Wall, I Lynch, R Wolfe, R L Cooper
Human error poses significant risk for hospitalized patients causing an estimated 100,000 to 400,000 deaths in the USA annually. Medication errors contribute, with error occurring in 5.3% of medication administrations during surgery. In this study 70.3% of medication errors were deemed preventable. Given the paucity of randomized controlled studies, we undertook a rigorous review of the literature to identify recommendations supported by expert opinions. An extensive literature search pertaining to medication error, medication safety, operating room, and anaesthesia was performed...
January 2017: British Journal of Anaesthesia
https://www.readbyqxmd.com/read/28034308/collagen-matrix-vs-mitomycin-c-in-trabeculectomy-and-combined-phacoemulsification-and-trabeculectomy-a-randomized-controlled-trial
#8
Angelo P Tanna, Alfred W Rademaker, C Gustavo de Moraes, David G Godfrey, Steven R Sarkisian, Steven D Vold, Robert Ritch
BACKGROUND: Antifibrotic agents are commonly utilized to enhance the success rates of trabeculectomy. Novel approaches to further improve success rates and reduce the risks of complications are needed. The purpose of this study was to compare intraocular pressure (IOP)-lowering efficacy and safety of trabeculectomy or combined phacoemulsification and trabeculectomy with mitomycin-C (MMC) vs. Collagen Matrix (CM). METHODS: A prospective, multicenter, randomized controlled trial was performed...
December 29, 2016: BMC Ophthalmology
https://www.readbyqxmd.com/read/28009600/the-detection-analysis-and-significance-of-physician-clustering-in-medical-malpractice-lawsuit-payouts
#9
Robert E Oshel, Philip Levitt
OBJECTIVES: There is evidence that most adverse events result from individual errors and that most malpractice suits with payouts reflect both patient injury and error. HYPOTHESIS: There are outlier physicians with regard to the frequency and total amount of malpractice payouts. METHODS: Using the public use file of the National Practitioner Data Bank (NPDB), we sought the percentage of physicians who lay above several cutoff points with regard to total amounts of payments and number of payments...
December 21, 2016: Journal of Patient Safety
https://www.readbyqxmd.com/read/27974226/adverse-event-and-error-of-unexpected-life-threatening-events-within-24h-of-emergency-department-admission
#10
Ewai Zhang, Shih-Chiang Hung, Chien-Hung Wu, Ling-Ling Chen, Ming-Ta Tsai, Wen-Huei Lee
OBJECTIVES: Errors and adverse events associated with unexpected life-threatening events including unplanned transfer to the intensive care unit (ICU) and unexpected death after emergency department (ED) hospitalization are not well characterized. We performed this study to investigate the role of unexpected life-threatening events as a trigger to capture errors and adverse events for ED patient safety. METHODS: This prospective observational study enrolled adult non-trauma patients with unexpected life-threatening events within 24h of general ward admission from the ED of a medical center in Taiwan...
November 30, 2016: American Journal of Emergency Medicine
https://www.readbyqxmd.com/read/27965416/a-patient-feedback-reporting-tool-for-opennotes-implications-for-patient-clinician-safety-and-quality-partnerships
#11
Sigall K Bell, Macda Gerard, Alan Fossa, Tom Delbanco, Patricia H Folcarelli, Kenneth E Sands, Barbara Sarnoff Lee, Jan Walker
BACKGROUND: OpenNotes, a national movement inviting patients to read their clinicians' notes online, may enhance safety through patient-reported documentation errors. OBJECTIVE: To test an OpenNotes patient reporting tool focused on safety concerns. METHODS: We invited 6225 patients through a patient portal to provide note feedback in a quality improvement pilot between August 2014 and 2015. A link at the end of the note led to a 9-question survey...
December 13, 2016: BMJ Quality & Safety
https://www.readbyqxmd.com/read/27940747/disclosure-of-adverse-events-in-pediatrics
#12
(no author information available yet)
Despite increasing attention to issues of patient safety, preventable adverse events (AEs) continue to occur, causing direct and consequential injuries to patients, families, and health care providers. Pediatricians generally agree that there is an ethical obligation to inform patients and families about preventable AEs and medical errors. Nonetheless, barriers, such as fear of liability, interfere with disclosure regarding preventable AEs. Changes to the legal system, improved communications skills, and carefully developed disclosure policies and programs can improve the quality and frequency of appropriate AE disclosure communications...
December 2016: Pediatrics
https://www.readbyqxmd.com/read/27919281/incidence-causes-and-consequences-of-preventable-adverse-drug-events-protocol-for-an-overview-of-reviews
#13
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
#14
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
#15
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
#16
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
#17
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
#18
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
#19
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
#20
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
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