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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/28934402/a-world-health-organization-field-trial-assessing-a-proposed-icd-11-framework-for-classifying-patient-safety-events
#1
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
#2
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
#3
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
#4
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
#5
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
#6
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
#7
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
#8
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
#9
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
#10
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
#11
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
#12
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
#13
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
#14
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
#15
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
#16
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
#17
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
#18
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
#19
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
#20
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
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