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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/29122210/strategies-to-increase-patient-safety-in-hemodialysis-application-of-the-modal-analysis-system-of-errors-and-effects-fema-system
#1
María Dolores Arenas Jiménez, Gabriel Ferre, Fernando Álvarez-Ude
BACKGROUND: Haemodialysis (HD) patients are a high-risk population group. For these patients, an error could have catastrophic consequences. Therefore, systems that ensure the safety of these patients in an environment with high technology and great interaction of the human factor is a requirement. OBJECTIVES: To show a systematic working approach, reproducible in any HD unit, which consists of recording the complications and errors that occurred during the HD session; defining which of those complications could be considered adverse event (AE), and therefore preventable; and carrying out a systematic analysis of them, as well as of underlying real or potential errors, evaluating their severity, frequency and detection; as well as establishing priorities for action (Failure Mode and Effects Analysis system [FMEA systems])...
November 2017: Nefrología: Publicación Oficial de la Sociedad Española Nefrologia
https://www.readbyqxmd.com/read/29076280/registered-nurses-perceptions-of-safe-care-in-overcrowded-emergency-departments
#2
Julia Eriksson, Linda Gellerstedt, Pernilla Hillerås, Åsa Gransjön Craftman
AIMS AND OBJECTIVE: To explore registered nurses' perceptions of safe practice in care for patients with an extended length of stay in the emergency department. BACKGROUND: Extended length of stay and overcrowding in emergency departments are described internationally as one of the most comprehensive challenges of modern emergency care. An emergency department is not designed, equipped or staffed to provide care for prolonged periods of time. This context, combined with a high workload, poses a risk to patient safety, with additional medical errors and an increased number of adverse events...
October 27, 2017: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/29064313/national-multispecialty-survey-results-comparing-morbidity-and-mortality-conference-practices-within-and-outside-otolaryngology
#3
Karthik Balakrishnan, Ellis M Arjmand, Brian Nussenbaum, And Carl Snyderman
Objective The objective is to describe variations in the otolaryngology morbidity and mortality (M&M) conference and to compare with other specialties. Design Cross-sectional survey. Setting The setting included otolaryngology departments across the United States and nonotolaryngology medical and surgical departments at 4 academic medical centers. Subjects and Methods Participants were members of a national otolaryngology quality/safety network and nonotolaryngology quality leaders at 4 large academic hospitals...
October 1, 2017: Otolaryngology—Head and Neck Surgery
https://www.readbyqxmd.com/read/29056178/root-cause-analysis-of-icu-adverse-events-in-the-veterans-health-administration
#4
Gregory S Corwin, Peter D Mills, Hasan Shanawani, Robin R Hemphill
BACKGROUND: ICUs' provision of complex care for critically ill patients results in an environment with a high potential for adverse events. A study was conducted to characterize adverse events in Veterans Health Administration (VHA) ICUs that underwent root cause analysis (RCA) and to identify the root causes and their recommended actions. METHODS: This retrospective observational study of RCA reports concerned events that occurred in VHA ICUs or as a result of ICU processes from January 1, 2013, through December 31, 2014...
November 2017: Joint Commission Journal on Quality and Patient Safety
https://www.readbyqxmd.com/read/29052704/patients-experiences-with-communication-and-resolution-programs-after-medical-injury
#5
MULTICENTER STUDY
Jennifer Moore, Marie Bismark, Michelle M Mello
Importance: Dissatisfaction with medical malpractice litigation has stimulated interest by health care organizations in developing alternatives to meet patients' needs after medical injury. In communication-and-resolution programs (CRPs), hospitals and liability insurers communicate with patients about adverse events, use investigation findings to improve patient safety, and offer compensation when substandard care caused harm. Despite increasing interest in this approach, little is known about patients' and family members' experiences with CRPs...
November 1, 2017: JAMA Internal Medicine
https://www.readbyqxmd.com/read/29035964/medication-safety-programs-in-primary-care-a-scoping-review
#6
Hanan Khalil, Monica Shahid, Libby Roughead
BACKGROUND: Medication safety plays an essential role in all healthcare organizations; improving this area is paramount to quality and safety of any wider healthcare program. While several medication safety programs in the hospital setting have been described and the associated impact on patient safety evaluated, no systematic reviews have described the impact of medication safety programs in the primary care setting. A preliminary search of the literature demonstrated that no systematic reviews, meta-analysis or scoping reviews have reported on medication safety programs in primary care; instead they have focused on specific interventions such as medication reconciliation or computerized physician order entry...
October 2017: JBI Database of Systematic Reviews and Implementation Reports
https://www.readbyqxmd.com/read/29032707/safety-of-psychiatric-inpatients-at-the-veterans-health-administration
#7
Steven C Marcus, Richard C Hermann, Martin R Frankel, Sara W Cullen
OBJECTIVE: Although reducing adverse events and medical errors has become a central focus of the U.S. health care system over the past two decades both within and outside the Veterans Health Administration (VHA) hospital systems, patients treated in psychiatric units of acute care general hospitals have been excluded from major research in this field. METHODS: The study included a random sample of 40 psychiatric units from medical centers in the national VHA system...
October 16, 2017: Psychiatric Services: a Journal of the American Psychiatric Association
https://www.readbyqxmd.com/read/28970058/measuring-harm-in-hospitalized-children-via-a-trigger-tool
#8
Lya M Stroupe, Kamakshya P Patra, Zheng Dai, Jeffrey Lancaster, Anjum Ahmed, Emily Merti, Robert Riley, Jamie Whitehair
BACKGROUND: The 1999 report To Err Is Human published by the Institute of Medicine estimated that between 44,000 and 98,000 deaths occur each year in US hospitals due to medical errors. However, processes to detect medically induced harm remain inaccurate and inconsistent. Hospitalized pediatric patients are at high risk for adverse events, with published rates ranging between 1% and 11% of all hospitalizations. OBJECTIVE: The study aimed to use the Global Assessment of Pediatric Patient Safety (GAPPS) tool to detect adverse events in a pediatric inpatient setting of an academic medical center children's hospital and compare to internal incident reporting methods...
September 29, 2017: Journal of Pediatric Nursing
https://www.readbyqxmd.com/read/28934402/a-world-health-organization-field-trial-assessing-a-proposed-icd-11-framework-for-classifying-patient-safety-events
#9
Alan J Forster, Burnand Bernard, Saskia E Drösler, Yana Gurevich, James Harrison, Jean-Marie Januel, Patrick S Romano, Danielle A Southern, Vijaya Sundararajan, Hude Quan, Saskia E Vanderloo, Harold A Pincus, William A Ghali
Objective: To assess the utility of the proposed World Health Organization (WHO)'s International Classification of Disease (ICD) framework for classifying patient safety events. Setting: Independent classification of 45 clinical vignettes using a web-based platform. Study participants: The WHO's multi-disciplinary Quality and Safety Topic Advisory Group. Main outcome measure(s): The framework consists of three concepts: harm, cause and mode...
August 1, 2017: International Journal for Quality in Health Care
https://www.readbyqxmd.com/read/28895231/software-related-recalls-of-health-information-technology-and-other-medical-devices-implications-for-fda-regulation-of-digital-health
#10
Jay G Ronquillo, Diana M Zuckerman
Policy Points: Medical software has become an increasingly critical component of health care, yet the regulation of these devices is inconsistent and controversial. No studies of medical devices and software assess the impact on patient safety of the FDA's current regulatory safeguards and new legislative changes to those standards. Our analysis quantifies the impact of software problems in regulated medical devices and indicates that current regulations are necessary but not sufficient for ensuring patient safety by identifying and eliminating dangerous defects in software currently on the market...
September 2017: Milbank Quarterly
https://www.readbyqxmd.com/read/28858143/facilitated-nurse-medication-related-event-reporting-to-improve-medication-management-quality-and-safety-in-intensive-care-units
#11
Jie Xu, Carrie Reale, Jason M Slagle, Shilo Anders, Matthew S Shotwell, Timothy Dresselhaus, Matthew B Weinger
BACKGROUND: Medication safety presents an ongoing challenge for nurses working in complex, fast-paced, intensive care unit (ICU) environments. Studying ICU nurse's medication management-especially medication-related events (MREs)-provides an approach to analyze and improve medication safety and quality. OBJECTIVES: The goal of this study was to explore the utility of facilitated MRE reporting in identifying system deficiencies and the relationship between MREs and nurses' work in the ICUs...
September 2017: Nursing Research
https://www.readbyqxmd.com/read/28841059/the-role-of-interpersonal-relations-in-healthcare-team-communication-and-patient-safety-a-proposed-model-of-interpersonal-process-in-teamwork
#12
Charlotte Tsz-Sum Lee, Diane Marie Doran
Patient safety is compromised by medical errors and adverse events related to miscommunications among healthcare providers. Communication among healthcare providers is affected by human factors, such as interpersonal relations. Yet, discussions of interpersonal relations and communication are lacking in healthcare team literature. This paper proposes a theoretical framework that explains how interpersonal relations among healthcare team members affect communication and team performance, such as patient safety...
June 2017: Canadian Journal of Nursing Research, Revue Canadienne de Recherche en Sciences Infirmières
https://www.readbyqxmd.com/read/28836363/improving-pharmacotherapy-outcomes-in-patients-with-hepatitis-c-virus-infection-treated-with-direct-acting-antivirals-the-gruvic-project
#13
Esther Chamorro-de-Vega, Carmen Guadalupe Rodriguez-Gonzalez, Alvaro Gimenez-Manzorro, Ana de Lorenzo-Pinto, Irene Iglesias-Peinado, Ana Herranz, Maria Sanjurjo
BACKGROUND/OBJECTIVE: Pharmaceutical care is needed in hepatitis C virus (HCV)-infected patients treated with direct-acting antivirals (DAA). We describe the implementation of a comprehensive pharmaceutical care programme (CPCP) for HCV-infected patients treated with DAA in a tertiary-care hospital and provide data about health outcomes and costs. METHODS: Quasi-experimental study between 1 April 2015 and 30 June 2016. A group of hospital pharmacists collaborating on HCV infection implemented interventional measures for validation of drug prescriptions, detection of clinically relevant drug-drug interactions and adverse drug events (ADEs), and patient education...
August 2017: International Journal of Clinical Practice
https://www.readbyqxmd.com/read/28834903/the-cost-saving-effect-and-prevention-of-medication-errors-by-clinical-pharmacist-intervention-in-a-nephrology-unit
#14
Chia-Chi Chen, Fei-Yuan Hsiao, Li-Jiuan Shen, Chien-Chih Wu
Medication errors may lead to adverse drug events (ADEs), which endangers patient safety and increases healthcare-related costs. The on-ward deployment of clinical pharmacists has been shown to reduce preventable ADEs, and save costs. The purpose of this study was to evaluate the ADEs prevention and cost-saving effects by clinical pharmacist deployment in a nephrology ward.This was a retrospective study, which compared the number of pharmacist interventions 1 year before and after a clinical pharmacist was deployed in a nephrology ward...
August 2017: Medicine (Baltimore)
https://www.readbyqxmd.com/read/28816851/clinical-practice-guideline-safe-medication-use-in-the-icu
#15
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
#16
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...
October 2017: Pharmacoepidemiology and Drug Safety
https://www.readbyqxmd.com/read/28802344/creating-a-highly-reliable-neonatal-intensive-care-unit-through-safer-systems-of-care
#17
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
#18
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)...
October 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
#19
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
#20
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
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