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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/28816851/clinical-practice-guideline-safe-medication-use-in-the-icu
#1
Sandra L Kane-Gill, Joseph F Dasta, Mitchell S Buckley, Sandeep Devabhakthuni, Michael Liu, Henry Cohen, Elisabeth L George, Anne S Pohlman, Swati Agarwal, Elizabeth A Henneman, Sharon M Bejian, Sean M Berenholtz, Jodie L Pepin, Mathew C Scanlon, Brian S Smith
OBJECTIVE: To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill. DATA SOURCES: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015. STUDY SELECTION: Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system...
September 2017: Critical Care Medicine
https://www.readbyqxmd.com/read/28815800/a-method-for-data-driven-exploration-to-pinpoint-key-features-in-medical-data-and-facilitate-expert-review
#2
Kristina Juhlin, Kristina Star, G Niklas Norén
PURPOSE: To develop a method for data-driven exploration in pharmacovigilance and illustrate its use by identifying the key features of individual case safety reports related to medication errors. METHODS: We propose vigiPoint, a method that contrasts the relative frequency of covariate values in a data subset of interest to those within one or more comparators, utilizing odds ratios with adaptive statistical shrinkage. Nested analyses identify higher order patterns, and permutation analysis is employed to protect against chance findings...
August 16, 2017: Pharmacoepidemiology and Drug Safety
https://www.readbyqxmd.com/read/28802344/creating-a-highly-reliable-neonatal-intensive-care-unit-through-safer-systems-of-care
#3
REVIEW
Patoula G Panagos, Stephen A Pearlman
Neonates requiring intensive care are at high risk for medical errors due to their unique characteristics and high acuity. Designing a safer work environment begins with safe processes. Creating a culture of safety demands the involvement of all organizational levels and an interdisciplinary approach. Adverse events can result from suboptimal communication and lack of a shared mental model. This chapter describes tools to promote better patient safety in the NICU through monitoring adverse events, improving communication and using information technology...
September 2017: Clinics in Perinatology
https://www.readbyqxmd.com/read/28776179/frequency-and-nature-of-medication-errors-and-adverse-drug-events-in-mental-health-hospitals-a-systematic-review
#4
REVIEW
Ghadah H Alshehri, Richard N Keers, Darren M Ashcroft
INTRODUCTION: Little is known about the frequency and nature of medication errors (MEs) and adverse drug events (ADEs) that occur in mental health hospitals. OBJECTIVES: This systematic review aims to provide an up-to-date and critical appraisal of the epidemiology and nature of MEs and ADEs in this setting. METHOD: Ten electronic databases were searched, including MEDLINE, Embase, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Scopus, British Nursing Index, ASSIA, Web of Science, and Cochrane Database of Systematic Reviews (1999 to October 2016)...
August 3, 2017: Drug Safety: An International Journal of Medical Toxicology and Drug Experience
https://www.readbyqxmd.com/read/28771756/visiting-nurses-posthospital-medication-management-in-home-health-care-an-ethnographic-study
#5
Mette Geil Kollerup, Tine Curtis, Birgitte Schantz Laursen
BACKGROUND: Medication management is the most challenging component of a successful transition from hospital to home, a challenge of growing complexity as the number of older persons living with chronic conditions grows, along with increasingly specialised and accelerated hospital treatment plans. Thus, many patients are discharged with complex medication regimen instructions, accentuating the risk of medication errors that may cause readmission, adverse drug events and a need for further health care...
August 3, 2017: Scandinavian Journal of Caring Sciences
https://www.readbyqxmd.com/read/28760793/pim-check-development-of-an-international-prescription-screening-checklist-designed-by-a-delphi-method-for-internal-medicine-patients
#6
Aude Desnoyer, Anne-Laure Blanc, Valérie Pourcher, Marie Besson, Caroline Fonzo-Christe, Jules Desmeules, Arnaud Perrier, Pascal Bonnabry, Caroline Samer, Bertrand Guignard
OBJECTIVES: Potentially inappropriate medication (PIM) occurs frequently and is a well-known risk factor for adverse drug events, but its incidence is underestimated in internal medicine. The objective of this study was to develop an electronic prescription-screening checklist to assist residents and young healthcare professionals in PIM detection. DESIGN: Five-step study involving selection of medical domains, literature review and 17 semistructured interviews, a two-round Delphi survey, a forward/back-translation process and an electronic tool development...
July 31, 2017: BMJ Open
https://www.readbyqxmd.com/read/28747134/reporting-medical-device-safety-incidents-to-regulatory-authorities-an-analysis-and-classification-of-technology-induced-errors
#7
Sari Palojoki, Kaija Saranto, Lasse Lehtonen
The European Union Medical Device Directive 2007/47/EC1 defines software with a medical purpose as a medical device. The implementation of health information technology suffers from patient safety problems that require effective post-market surveillance. The purpose of this study was to review, classify and discuss the incident data submitted to a nationwide database of the Finnish National Competent Authority with other forms of data. We analysed incident reports submitted to the authority database by users of electronic health records from 2010 to 2015...
July 1, 2017: Health Informatics Journal
https://www.readbyqxmd.com/read/28728430/patient-handoff-education-are-medical-schools-catching-up
#8
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
#9
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
#10
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
#11
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
#12
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
#13
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
#14
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
#15
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
#16
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
#17
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
#18
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
#19
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
#20
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
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