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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/29730898/avoidance-of-overt-precipitation-and-patient-harm-following-errant-y-site-administration-of-calcium-chloride-and-parenteral-nutrition-compounded-with-sodium-glycerophosphate
#1
Collin Anderson, Chanelle Stidham, Sabrina Boehme, Jared Cash
Calcium phosphate precipitates present 1 of many challenges associated with parenteral nutrition (PN) compounding. Extensive research has led to the establishment of solubility curves to guide practitioners in the prescription and preparation of stable PN. Concurrent dosing of intravenous products via y-site administration with PN can alter the chemical balance of the solution and modify solubility. Medications containing calcium or phosphate should not be administered in the same line as PN, due to the high potential for precipitation...
December 14, 2017: Nutrition in Clinical Practice
https://www.readbyqxmd.com/read/29730617/what-is-the-epidemiology-of-medication-errors-error-related-adverse-events-and-risk-factors-for-errors-in-adults-managed-in-community-care-contexts-a-systematic-review-of-the-international-literature
#2
Ghadah Asaad Assiri, Nada Atef Shebl, Mansour Adam Mahmoud, Nouf Aloudah, Elizabeth Grant, Hisham Aljadhey, Aziz Sheikh
OBJECTIVE: To investigate the epidemiology of medication errors and error-related adverse events in adults in primary care, ambulatory care and patients' homes. DESIGN: Systematic review. DATA SOURCE: Six international databases were searched for publications between 1 January 2006 and 31 December 2015. DATA EXTRACTION AND ANALYSIS: Two researchers independently extracted data from eligible studies and assessed the quality of these using established instruments...
May 5, 2018: BMJ Open
https://www.readbyqxmd.com/read/29699556/the-struggle-against-perceived-negligence-a-qualitative-study-of-patients-experiences-of-adverse-events-in-norwegian-hospitals
#3
Gunn Hågensen, Gudrun Nilsen, Grete Mehus, Nils Henriksen
BACKGROUND: Every year, 14 % of patients in Norwegian hospitals experience adverse events, which often have health-damaging consequences. The government, hospital management and health personnel attempt to minimize such events. Limited research on the first-hand experience of the patients affected is available. The aim of this study is to present patients' perspectives of the occurrence of, disclosure of, and healthcare organizations' responses to adverse events. Findings are discussed within a social constructivist framework and with reference to principles of open disclosure policy...
April 25, 2018: BMC Health Services Research
https://www.readbyqxmd.com/read/29691927/safety-and-efficacy-following-10-years-of-overnight-orthokeratology-for-myopia-control
#4
Takahiro Hiraoka, Yasuo Sekine, Fumiki Okamoto, Toshifumi Mihashi, Tetsuro Oshika
PURPOSE: To compare rates of myopia progression and adverse events between orthokeratology (OK) and soft contact lens (SCL) wearers over a 10-year period in schoolchildren. METHODS: Medical records of consecutive patients (≤16 years of age at baseline) who started OK for myopia correction and continued the treatment for 10 years were retrospectively reviewed. For the control group, patients who started using soft contact lenses (SCLs) for myopia correction and continued to use them for 10 years were also reviewed...
May 2018: Ophthalmic & Physiological Optics: the Journal of the British College of Ophthalmic Opticians (Optometrists)
https://www.readbyqxmd.com/read/29624979/inappropriate-prescribing-in-older-adults-critical-review-of-the-literature-and-safety-alerts
#5
Dolores Mino-León, María Eugenia Galván-Plata, Anda-Garay Anda-GarayJuan Carlos, Maura Estela Noyola-García, Davis Cooper
Background: Prescribing errors are a risk factor for patients to present adverse events and a strategy that has been incorporated into medical care to reduce them is the use of computer tools. The objective was to obtain the scientific basis for the development of prescribing error alerts for four chronic diseases with a higher prevalence in population ≥ 65 years. Methods: We reviewed the literature from 2010 to 2015 to obtain information about adverse events and adverse drug reactions associated with the use of drugs for the treatment of diabetes mellitus type 2 (DM2), hypertension, osteoarticular diseases (OD) and depression; the review included these databases: PubMed, OVID, Cochrane Library, LILACS, MEDES, Portal Mayores and SIETES...
2018: Revista Médica del Instituto Mexicano del Seguro Social
https://www.readbyqxmd.com/read/29601529/assessing-the-health-care-risk-the-clinical-var-a-key-indicator-for-sound-management
#6
Enrique Jiménez-Rodríguez, José Manuel Feria-Domínguez, Alonso Sebastián-Lacave
Clinical risk includes any undesirable situation or operational factor that may have negative consequences for patient safety or capable of causing an adverse event (AE). The AE, intentional or unintentionally, may be related to the human factor, that is, medical errors (MEs). Therefore, the importance of the health-care risk management is a current and relevant issue on the agenda of many public and private institutions. The objective of the management has been evolving from the identification of AE to the assessment of cost-effective and efficient measures that improve the quality control through monitoring...
March 30, 2018: International Journal of Environmental Research and Public Health
https://www.readbyqxmd.com/read/29563021/improving-detection-of-intraoperative-medical-errors-imes-and-intraoperative-adverse-events-iaes-and-their-contribution-to-postoperative-outcomes
#7
Qi Chen, Amy K Rosen, Houman Amirfarzan, Alexandra Rochman, Kamal M F Itani
Our knowledge of the types of intraoperative patient safety events, their harm to patients, and relationship to postoperative complications is sparse. This study examined intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) voluntarily reported by providers using two programs at our hospital: surgical debriefing and incident reporting. Among the 3020 surgical procedures assessed, 142 iMEs and 103 iAEs were reported, yielding an overall rate of 8%. Of these events, 135 (55%) were obtained from incident reporting and 110 (45%) from surgical debriefing...
March 6, 2018: American Journal of Surgery
https://www.readbyqxmd.com/read/29558835/views-of-children-parents-and-health-care-providers-on-pediatric-disclosure-of-medical-errors
#8
Donna Koller, Sherry Espin
Despite the prevalence of medical errors in pediatrics, little research examines stakeholder perspectives on the disclosure of adverse events, particularly in the case of children's own perspectives. Stakeholder perspectives, however, are integral to informing processes for pediatric disclosure. Building on a systematic review of the literature, this article presents findings from a series of focus groups with key pediatric stakeholders where perspectives were sought on the disclosure of medical errors. Focus groups were conducted with three stakeholder groups...
January 1, 2018: Journal of Child Health Care: for Professionals Working with Children in the Hospital and Community
https://www.readbyqxmd.com/read/29553444/improving-patient-safety-in-palestinian-hospitals-a-cross-sectional-and-retrospective-chart-review-study
#9
Shahenaz Najjar, Nashat Nafouri, Kris Vanhaecht, Martin Euwema
BACKGROUND: Patient safety is the central component of health-care quality. There is a lack of patient safety data in the occupied Palestinian territory. The aim of this study was to assess patient safety and explore relationships between patient safety culture and the prevalence of adverse events at the department level. METHODS: Between May 25, 2009, and June 1, 2010, the Arabic validated Hospital Survey on Patient Safety Culture was used to measure the norms and perceptions of health professionals regarding safety...
February 21, 2018: Lancet
https://www.readbyqxmd.com/read/29513262/should-patients-with-brain-implants-undergo-mri
#10
Johannes B Erhardt, Erwin Fuhrer, Oliver G Gruschke, Jochen Leupold, Matthias C Wapler, Jürgen Hennig, Thomas Stieglitz, Jan G Korvink
Patients suffering from neuronal degenerative diseases are increasingly being equipped with neural implants to treat symptoms or restore functions and increase their quality of life. Magnetic resonance imaging (MRI) would be the modality of choice for the diagnosis and compulsory postoperative monitoring of such patients. However, interactions between the magnetic resonance (MR) environment and implants pose severe health risks to the patient. Nevertheless, neural implant recipients regularly undergo MRI examinations, and adverse events are rarely reported...
March 7, 2018: Journal of Neural Engineering
https://www.readbyqxmd.com/read/29500161/improving-transplant-medication-safety-through-a-pharmacist-empowered-patient-centered-mhealth-based-intervention-transafe-rx-study-protocol
#11
James N Fleming, Frank Treiber, John McGillicuddy, Mulugeta Gebregziabher, David J Taber
BACKGROUND: Medication errors, adverse drug events, and nonadherence are the predominant causes of graft loss in kidney transplant recipients and lead to increased healthcare utilization. Research has demonstrated that clinical pharmacists have the unique education and training to identify these events early and develop strategies to mitigate or prevent downstream sequelae. In addition, studies utilizing mHealth interventions have demonstrated success in improving the control of chronic conditions that lead to kidney transplant deterioration...
March 2, 2018: JMIR Research Protocols
https://www.readbyqxmd.com/read/29456450/survey-on-patient-safety-culture-in-the-republic-of-moldova-a-baseline-study-in-three-healthcare-settings
#12
Carmen Tereanu, Giuseppe Sampietro, Francesco Sarnataro, Dumitru Siscanu, Rodica Palaria, Victor Savin, Tatiana Cliscovscaia, Valentina Pislaru, Valeriu Oglinda, Larisa Capmare, Mugurel Stefan Ghelase, Tamara Turcanu
Background and aims: The Republic of Moldova is a small ex-soviet country in the Central Eastern European group of states, whose official language is Romanian. In countries with limited resources, quality improvement in healthcare and patient safety are very challenging. This study aims to identify which areas of the patient safety culture (PSC) need prompt intervention. Methods: A cross-sectional study was conducted in three Moldovan healthcare settings, using the Romanian translation of the US Hospital Survey on Patient Safety Culture HSOPSC...
2018: Clujul Medical (1957)
https://www.readbyqxmd.com/read/29417295/the-effect-of-a-medication-reconciliation-program-in-two-intensive-care-units-in-the-netherlands-a-prospective-intervention-study-with-a-before-and-after-design
#13
Liesbeth B E Bosma, Nicole G M Hunfeld, Rogier A M Quax, Edmé Meuwese, Piet H G J Melief, Jasper van Bommel, SiokSwan Tan, Maaike J van Kranenburg, Patricia M L A van den Bemt
BACKGROUND: Medication errors occur frequently in the intensive care unit (ICU) and during care transitions. Chronic medication is often temporarily stopped at the ICU. Unfortunately, when the patient improves, the restart of this medication is easily forgotten. Moreover, temporal ICU medication is often unintentionally continued after ICU discharge. Medication reconciliation could be useful to prevent such errors. Therefore, the aim of this study was to determine the effect of medication reconciliation at the ICU...
February 7, 2018: Annals of Intensive Care
https://www.readbyqxmd.com/read/29389330/research-techniques-made-simple-pharmacoepidemiology-research-methods-in-dermatology
#14
Megan H Noe, Joel M Gelfand
Clinical trials have several important limitations for evaluating the safety of new medications, leading to many adverse events not being identified until the postmarketing period. Descriptive studies, including case reports, case series, cross-sectional, and ecologic studies, help identify potential safety signals and generate hypotheses. Further research using analytic study methods, including case-control studies and cohort studies, are necessary to determine if an association truly exists and to better understand the potential for causation...
February 2018: Journal of Investigative Dermatology
https://www.readbyqxmd.com/read/29356714/disclosure-of-harmful-medical-error-to-patients-a-review-with-recommendations-for-pathologists
#15
Yael K Heher, Suzanne M Dintzis
Harmful error is an infrequent but serious challenge in the pathology laboratory. Regulatory bodies and advocacy groups have mandated and encouraged disclosure of error to patients. Many pathologists are interested in participating in disclosure of harmful error but are ill-equipped to do so. This review of the literature with recommendations examines the current state of the patient safety movement and error disclosure as it pertains to pathology and provides a practical and explicit guide for pathologists for who, when, and how to disclose harmful pathology error to patients...
March 2018: Advances in Anatomic Pathology
https://www.readbyqxmd.com/read/29346222/-to-err-is-human-but-disclosure-must-be-taught-a-simulation-based-assessment-study
#16
Ashley C Crimmins, Ambrose H Wong, James W Bonz, Alina Tsyrulnik, Karen Jubanyik, James D Dziura, Kelly L Dodge, Leigh V Evans
INTRODUCTION: Although error disclosure is critical in promoting safety and patient-centered care, physicians are inconsistently trained in its practice, and few objective methods to assess competence exist. We used an immersive simulation scenario to determine whether providers with varying levels of clinical experience adhere to the disclosure safe practice guidelines when exposed to a serious adverse event simulation scenario. METHODS: This was a prospective cohort study with medical students, junior emergency medicine (EM) residents (PGY 1-2), senior EM residents (PGY 3-4), and attending EM physicians participating in a simulated case in which a scripted medication overdose resulted in an adverse event...
April 2018: Simulation in Healthcare: Journal of the Society for Simulation in Healthcare
https://www.readbyqxmd.com/read/29330246/the-accuracy-of-trigger-tools-to-detect-preventable-adverse-events-in-primary-care-a-systematic-review
#17
Joshua Davis, Nicole Harrington, Heather Bittner Fagan, Barbara Henry, Margot Savoy
PURPOSE: To understand the ability of trigger tools to detect preventable adverse events (pAEs) in the primary care outpatient setting using the Institute for Healthcare Improvement's (IHI) Outpatient Adverse Event Trigger Tool (IHI Tool). METHODS: The OVID MEDLINE and OVID MEDLINE In-process and non-Indexed citations databases were queried using controlled vocabulary and Medical Subject Headings related to the concepts "primary care" and "adverse events...
January 2018: Journal of the American Board of Family Medicine: JABFM
https://www.readbyqxmd.com/read/29310711/impact-of-collaborative-pharmaceutical-care-on-in-patients-medication-safety-study-protocol-for-a-stepped-wedge-cluster-randomized-trial-medrev-study
#18
Géraldine Leguelinel-Blache, Christel Castelli, Clarisse Roux-Marson, Sophie Bouvet, Sandrine Andrieu, Philippe Cestac, Rémy Collomp, Paul Landais, Bertrice Loulière, Christelle Mouchoux, Rémi Varin, Benoit Allenet, Pierrick Bedouch, Jean-Marie Kinowski
BACKGROUND: Clinical pharmaceutical care has long played an important role in the improvement of healthcare safety. Pharmaceutical care is a collaborative care approach, implicating all the actors of the medication circuit in order to prevent and correct drug-related problems that can lead to adverse drug events. The collaborative pharmaceutical care performed during patients' hospitalization requires two mutually reinforcing activities: medication reconciliation and medication review...
January 8, 2018: Trials
https://www.readbyqxmd.com/read/29274807/deintensification-of-hypoglycaemic-medications-use-of-a-systematic-review-approach-to-highlight-safety-concerns-in-older-people-with-type-2-diabetes
#19
REVIEW
A H Abdelhafiz, A J Sinclair
IMPORTANCE: Intensive treatment of older people with diabetes is common placing them at increased risk of adverse events such as hypoglycaemia and hospitalisation for drug errors. Little is known about when, how or for whom to deintensify hypoglycaemic medications. OBJECTIVE: To explore the characteristics of patients for whom deintensification is appropriate and to determine the outcome of deintensification. EVIDENCE REVIEW: Medline, Google scholar and EmBase search from 1997 to present was performed using keywords relating to diabetes mellitus, polypharmacy, hypoglycaemia, hospitalisation, deintensification, deprescribing and reduction, simplification or withdrawal of hypoglycaemic medications...
April 2018: Journal of Diabetes and its Complications
https://www.readbyqxmd.com/read/29259940/assessment-of-orthographic-similarity-of-drugs-names-between-iran-and-overseas-using-the-solar-model
#20
Nazanin Abolhassani, Ali Akbari Sari, Arash Rashidian, Mansoor Rastegarpanah
Background: The recognition of patient safety is now occupying a prominent place on the health policy agenda since medical errors can result in adverse events. The existence of confusing drug names is one of the most common causes of medication errors. In Iran, the General Office of Trademarks Registry (GOTR), for four years (2010-2014) was responsible for approving drug proprietary names. This study aimed to investigate the performance of the GOTR in terms of drug names orthographic similarity using the SOLAR model...
December 2017: Iranian Journal of Public Health
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