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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/28272647/the-impact-of-information-culture-on-patient-safety-outcomes-development-of-a-structural-equation-model
#1
Virpi Jylhä, Santtu Mikkonen, Kaija Saranto, David W Bates
BACKGROUND: An organization's information culture and information management practices create conditions for processing patient information in hospitals. Information management incidents are failures that could lead to adverse events for the patient if they are not detected. OBJECTIVES: To test a theoretical model that links information culture in acute care hospitals to information management incidents and patient safety outcomes. METHODS: Reason's model for the stages of development of organizational accidents was applied...
March 8, 2017: Methods of Information in Medicine
https://www.readbyqxmd.com/read/28259386/proper-management-of-medications-to-limit-errors-what-the-oral-surgeon-should-know-to-limit-medication-errors-and-adverse-drug-events
#2
REVIEW
Daniel S Sarasin, Jarom E Mauer
Providing safe and effective ambulatory anesthesia is a key component in delivering optimal care to oral and maxillofacial patients. Unfortunately, medication errors and adverse drug events (ADEs) occur in offices, as they do in hospital operating rooms. Preparing and delivering medication seems simple. In reality, this is a complex process with multiple opportunities for drug errors leading to actual or potential ADEs. This article reviews medication errors and ADEs, introduces a medication safety paradigm for oral and maxillofacial surgery facilities, and provides practical safety initiatives that can be implemented to achieve the goal of optimal anesthesia patient care and safety...
March 1, 2017: Oral and Maxillofacial Surgery Clinics of North America
https://www.readbyqxmd.com/read/28248748/informing-the-design-of-a-new-pragmatic-registry-to-stimulate-near-miss-reporting-in-ambulatory-care
#3
Elizabeth R Pfoh, Lilly Engineer, Hardeep Singh, Laura Lee Hall, Ethan D Fried, Zackary Berger, Albert W Wu
OBJECTIVE: Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents...
February 28, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28242191/comprehensive-literature-review-of-factors-influencing-medication-safety-in-nursing-homes-using-a-systems-model
#4
REVIEW
Ali Azeez Al-Jumaili, William R Doucette
OBJECTIVES: The objectives of this review were to identify the work system factors influencing medication safety measures [adverse drug events (ADEs), adverse drug reactions, or medication errors (MEs)], to determine the incidence of ADEs, and describe the most common ADEs in nursing homes (NHs). METHODS: A comprehensive literature review was conducted using PubMed and CINAHL to identify studies investigating factors that influence ADEs, adverse drug reactions, and MEs in NHs and skilled nursing facilities...
February 24, 2017: Journal of the American Medical Directors Association
https://www.readbyqxmd.com/read/28241211/families-as-partners-in-hospital-error-and-adverse-event-surveillance
#5
Alisa Khan, Maitreya Coffey, Katherine P Litterer, Jennifer D Baird, Stephannie L Furtak, Briana M Garcia, Michele A Ashland, Sharon Calaman, Nicholas C Kuzma, Jennifer K O'Toole, Aarti Patel, Glenn Rosenbluth, Lauren A Destino, Jennifer L Everhart, Brian P Good, Jennifer H Hepps, Anuj K Dalal, Stuart R Lipsitz, Catherine S Yoon, Katherine R Zigmont, Rajendu Srivastava, Amy J Starmer, Theodore C Sectish, Nancy D Spector, Daniel C West, Christopher P Landrigan, Brenda K Allair, Claire Alminde, Wilma Alvarado-Little, Marisa Atsatt, Megan E Aylor, James F Bale, Dorene Balmer, Kevin T Barton, Carolyn Beck, Zia Bismilla, Rebecca L Blankenberg, Debra Chandler, Amanda Choudhary, Eileen Christensen, Sally Coghlan-McDonald, F Sessions Cole, Elizabeth Corless, Sharon Cray, Roxi Da Silva, Devesh Dahale, Benard Dreyer, Amanda S Growdon, LeAnn Gubler, Amy Guiot, Roben Harris, Helen Haskell, Irene Kocolas, Elizabeth Kruvand, Michele Marie Lane, Kathleen Langrish, Christy J W Ledford, Kheyandra Lewis, Joseph O Lopreiato, Christopher G Maloney, Amanda Mangan, Peggy Markle, Fernando Mendoza, Dale Ann Micalizzi, Vineeta Mittal, Maria Obermeyer, Katherine A O'Donnell, Mary Ottolini, Shilpa J Patel, Rita Pickler, Jayne Elizabeth Rogers, Lee M Sanders, Kimberly Sauder, Samir S Shah, Meesha Sharma, Arabella Simpkin, Anupama Subramony, E Douglas Thompson, Laura Trueman, Tanner Trujillo, Michael P Turmelle, Cindy Warnick, Chelsea Welch, Andrew J White, Matthew F Wien, Ariel S Winn, Stephanie Wintch, Michael Wolf, H Shonna Yin, Clifton E Yu
Importance: Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective: To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports...
February 27, 2017: JAMA Pediatrics
https://www.readbyqxmd.com/read/28213602/understanding-the-epidemiology-of-avoidable-significant-harm-in-primary-care-protocol-for-a-retrospective-cross-sectional-study
#6
Brian G Bell, Stephen Campbell, Andrew Carson-Stevens, Huw Prosser Evans, Alison Cooper, Christina Sheehan, Sarah Rodgers, Christine Johnson, Adrian Edwards, Sarah Armstrong, Rajnikant Mehta, Antony Chuter, Ailsa Donnelly, Darren M Ashcroft, Joanne Lymn, Pam Smith, Aziz Sheikh, Matthew Boyd, Anthony J Avery
INTRODUCTION: Most patient safety research has focused on specialist-care settings where there is an appreciation of the frequency and causes of medical errors, and the resulting burden of adverse events. There have, however, been few large-scale robust studies that have investigated the extent and severity of avoidable harm in primary care. To address this, we will conduct a 12-month retrospective cross-sectional study involving case note review of primary care patients. METHODS AND ANALYSIS: We will conduct electronic searches of general practice (GP) clinical computer systems to identify patients with avoidable significant harm...
February 17, 2017: BMJ Open
https://www.readbyqxmd.com/read/28192533/improving-medication-safety-development-and-impact-of-a-multivariate-model-based-strategy-to-target-high-risk-patients
#7
Tri-Long Nguyen, Géraldine Leguelinel-Blache, Jean-Marie Kinowski, Clarisse Roux-Marson, Marion Rougier, Jessica Spence, Yannick Le Manach, Paul Landais
BACKGROUND: Preventive strategies to reduce clinically significant medication errors (MEs), such as medication review, are often limited by human resources. Identifying high-risk patients to allow for appropriate resource allocation is of the utmost importance. To this end, we developed a predictive model to identify high-risk patients and assessed its impact on clinical decision-making. METHODS: From March 1st to April 31st 2014, we conducted a prospective cohort study on adult inpatients of a 1,644-bed University Hospital Centre...
2017: PloS One
https://www.readbyqxmd.com/read/28191498/a-prospective-study-of-patient-safety-incidents-in-gastrointestinal-endoscopy
#8
Manmeet Matharoo, Adam Haycock, Nick Sevdalis, Siwan Thomas-Gibson
Background and study aims Medical error occurs frequently with significant morbidity and mortality. This study aime to assess the frequency and type of endoscopy patient safety incidents (PSIs). Patients and methods A prospective observational study of PSIs in routine diagnostic and therapeutic endoscopy was undertaken in a secondary and tertiary care center. Observations were undertaken within the endoscopy suite across pre-procedure, intra-procedure and post-procedure phases of care. Experienced (Consultant-level) and trainee endoscopists from medical, surgical, and nursing specialities were included...
January 2017: Endoscopy International Open
https://www.readbyqxmd.com/read/28187011/estimating-hospital-related-deaths-due-to-medical-error-a-perspective-from-patient-advocates
#9
Kevin T Kavanagh, Daniel M Saman, Rosie Bartel, Kim Westerman
The authors present a viewpoint regarding the quality of data used in estimating the number of preventable hospital deaths in the United States. Data derived from countries with a nationalized healthcare system with well-defined and near uniform implementation of standards may not be applicable to the fragmented noncentralized delivery system found in the United States. Although U.S. studies evaluating preventable mortality have based their projections on a small sample size, it is unlikely that this observation is due to chance, because other studies evaluating adverse events, a precursor to preventable mortality, have a much larger sample size and also report an unacceptably high number of events...
March 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28185075/paediatric-patient-safety-and-the-need-for-aviation-black-box-thinking-to-learn-from-and-prevent-medication-errors
#10
Chi Huynh, Ian C K Wong, Jo Correa-West, David Terry, Suzanne McCarthy
Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors...
April 2017: Paediatric Drugs
https://www.readbyqxmd.com/read/28183302/the-effect-of-the-tim-program-transfer-icu-medication-reconciliation-on-medication-transfer-errors-in-two-dutch-intensive-care-units-design-of-a-prospective-8-month-observational-study-with-a-before-and-after-period
#11
Bertha Elizabeth Bosma, Edmé Meuwese, Siok Swan Tan, Jasper van Bommel, Piet Herman Gerard Jan Melief, Nicole Geertruida Maria Hunfeld, Patricia Maria Lucia Adriana van den Bemt
BACKGROUND: The transfer of patients to and from the Intensive Care Unit (ICU) is prone to medication errors. The aim of the present study is to determine whether the number of medication errors at ICU admission and discharge and the associated potential harm and costs are reduced by using the Transfer ICU and Medication reconciliation (TIM) program. METHODS: This prospective 8-month observational study with a pre- and post-design will assess the effects of the TIM program compared with usual care in two Dutch hospitals...
February 10, 2017: BMC Health Services Research
https://www.readbyqxmd.com/read/28170093/topical-treatments-for-blepharokeratoconjunctivitis-in-children
#12
REVIEW
Michael O'Gallagher, Catey Bunce, Melanie Hingorani, Frank Larkin, Stephen Tuft, Annegret Dahlmann-Noor
BACKGROUND: Blepharokeratoconjunctivitis (BKC) is a type of inflammation of the surface of the eye and eyelids that involves changes of the eyelids, dysfunction of the meibomian glands, and inflammation of the conjunctiva and cornea. Chronic inflammation of the cornea can lead to scarring, vascularisation and opacity. BKC in children can cause significant symptoms including irritation, watering, photophobia and loss of vision from corneal opacity, refractive error or amblyopia.Treatment of BKC is directed towards modification of meibomian gland disease and the bacterial flora of lid margin and conjunctiva, and control of ocular surface inflammation...
February 7, 2017: Cochrane Database of Systematic Reviews
https://www.readbyqxmd.com/read/28157394/how-well-prepared-are-medical-and-nursing-students-to-identify-common-hazards-in-the-icu
#13
Alison S Clay, Saumil M Chudgar, Kathleen M Turner, Jacqueline Vaughn, Nancy W Knudsen, Jeanne M Farnan, Vineet M Arora, Margory A Molloy
RATIONALE: Care in the hospital is hazardous. Harm in the hospital may prolong hospitalization, increase suffering, result in death, and increase costs of care. While the interprofessional team is critical to eliminating hazards that may result in adverse events to patients, professional students' formal education may not prepare students adequately for this role. OBJECTIVES: To determine if medical and nursing students can identify hazards of hospitalization that could result in harm to patients and to detect differences between professions in the types of hazards identified...
February 3, 2017: Annals of the American Thoracic Society
https://www.readbyqxmd.com/read/28152936/improving-transitions-of-care-through-implementation-of-a-standardized-handoff-at-a-comprehensive-cancer-center
#14
Mohamed Ait Aiss, Helene P Phu, Lakeisha R Day, Varkey Abraham, Karen Chen, Mejia Rodrigo, Shehla Razvi, Carmen E Gonzalez, Norman Brito-Dellan, Srinivas Banala, David Rubio, Nicole Vaughan-Adams, Debra S Ruiz, Tan Jens, Charles F Levenback, Michael M Frumovitz, Behrouz Zand, Carmelita P Escalante
242 Background: Communication failures cause two-thirds of sentinel events in hospitals. These adverse occurrences are often both fatal and preventable. Consequently, improving the quality of handoffs has been identified by multiple accreditation constituents as a top priority patient safety goal. This project was part of an institutional initiative to standardize handoffs among physicians, trainees, and midlevel providers. METHODS: Four subgroups were identified as pilot areas: Gynecologic Oncology (Gyn Onc) fellows to nocturnalists, Surgical Oncology fellows, Pediatric Oncology residents and fellows, and Emergency Center attending staff to inpatient hospitalists...
March 2016: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28138316/characterizing-a-naturalistic-decision-making-phenomenon-loss-of-system-resilience-associated-with-implementation-of-new-technology
#15
Emily S Patterson, Laura G Militello, George Su, Urmimala Sarkar
We describe a phenomenon viewed through the conceptual lens of a naturalistic decision making perspective: a loss of system resilience, due to increased difficulty in performing macrocognition functions, associated with the implementation of new information technology. Examples of the phenomenon collected in a targeted literature review are characterized by stakeholder groups, technology, typical changes in workflow before and after implementation, and potential impacts on macrocognition and patient outcomes for four clinical care environments...
September 2016: Journal of Cognitive Engineering and Decision Making
https://www.readbyqxmd.com/read/28112578/safety-of-cancer-therapies-at-what-cost
#16
Karen Fitzner, Frederick Oteng-Mensah, Patrick Donley, Elizabeth A F Heckinger
The cost of cancer drugs has increased concurrently with drug safety resulting in both increased survivorship and increased out-of-pocket costs and co-payments for patients. This article evaluates the interplay between patient safety and cancer drug costs to determine how cancer drug costs affect patient safety and well-being. A literature review was performed that identified the main drivers of drug safety costs: drug-drug interactions, adverse drug events, medication errors, and nonadherence. Three main types of costs were identified: out-of-pocket spending, drug cost growth, and safety-related costs...
January 23, 2017: Population Health Management
https://www.readbyqxmd.com/read/28110223/guilt-without-fault-a-qualitative-study-into-the-ethics-of-forgiveness-after-traumatic-childbirth
#17
Katja Schrøder, Karen la Cour, Jan Stener Jørgensen, Ronald F Lamont, Niels Christian Hvidt
When a life is lost or severely impaired during childbirth, the midwife and obstetrician involved may experience feelings of guilt in the aftermath. Through three empirical cases, the paper examines the sense of guilt in the context of the current patient safety culture in healthcare where a blame-free approach is promoted in the aftermath of adverse events. The purpose is to illustrate how healthcare professionals may experience guilt without being at fault after adverse events, and Gamlund's theory on forgiveness without blame is used as the theoretical framework for this analysis...
January 16, 2017: Social Science & Medicine
https://www.readbyqxmd.com/read/28103397/the-economic-burden-of-nurse-sensitive-adverse-events-in-22-medical-surgical-units-retrospective-and-matching-analysis
#18
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
#19
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
#20
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
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