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Patient Safety, Adverse Events, Medical Error

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https://www.readbyqxmd.com/read/29330246/the-accuracy-of-trigger-tools-to-detect-preventable-adverse-events-in-primary-care-a-systematic-review
#1
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." Included articles were conducted in the outpatient setting, used at least 1 of the triggers identified in the IHI Tool, and identified pAEs of any type...
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
#2
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
#3
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...
November 29, 2017: 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
#4
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
https://www.readbyqxmd.com/read/29258599/transition-in-care-from-paramedics-to-emergency-department-nurses-a-systematic-review-protocol
#5
Gudrun Reay, Jill M Norris, K Alix Hayden, Joanna Abraham, Katherine Yokom, Lorelli Nowell, Gerald C Lazarenko, Eddy S Lang
BACKGROUND: Effective and efficient transitions in care between emergency medical services (EMS) practitioners and emergency department (ED) nurses is vital as poor clinical transitions in care may place patients at increased risk for adverse events such as delay in treatment for time sensitive conditions (e.g., myocardial infarction) or worsening of status (e.g., sepsis). Such transitions in care are complex and prone to communication errors primarily caused by misunderstanding related to divergent professional perspectives leading to misunderstandings that are further susceptible to contextual factors and divergent professional lenses...
December 19, 2017: Systematic Reviews
https://www.readbyqxmd.com/read/29248986/the-impact-of-pharmacist-led-medication-reconciliation-during-admission-at-tertiary-care-hospital
#6
Khulood H Abdulghani, Mohammed A Aseeri, Ahmed Mahmoud, Rayf Abulezz
Background Medication errors represent the most common type of error that compromises patient safety, with approximately 20% believed to result in harm. Over 40% of these errors are believed to result from inadequate medication reconciliation during admission, transfer, and discharge of patients and many of these errors could be prevented if adequate medication reconciliation processes were in place. In an effort to minimize adverse events caused during these care transitions, the Joint Commission has stated medication reconciliation as one of its National Patient Safety Goals and health care providers and organizations are encouraged to perform the process at various patient care transitions...
December 16, 2017: International Journal of Clinical Pharmacy
https://www.readbyqxmd.com/read/29228295/assessment-of-patient-safety-culture-in-private-and-public-hospitals-in-peru
#7
Alejandro Arrieta, Gabriela Suárez, Galed Hakim
Objective: To assess the patient safety culture in Peruvian hospitals from the perspective of healthcare professionals, and to test for differences between the private and public healthcare sectors. Patient safety is defined as the avoidance and prevention of patient injuries or adverse events resulting from the processes of healthcare delivery. Design: A non-random cross-sectional study conducted online. Setting: An online survey was administered from July to August 2016, in Peru...
December 8, 2017: International Journal for Quality in Health Care
https://www.readbyqxmd.com/read/29206706/quantifying-dental-office-originating-adverse-events-the-dental-practice-study-methods
#8
Oluwabunmi Tokede, Muhammad Walji, Rachel Ramoni, Donald B Rindal, Donald Worley, Nutan Hebballi, Krishna Kumar, Claire van Strien, Mengxia Chen, Shaked Navat-Pelli, Hongchun Liu, Jini Etolue, Alfa Yansane, Enihomo Obadan-Udoh, Casey Easterday, Chris Enstad, Sheryl Kane, William Rush, Elsbeth Kalenderian
BACKGROUND: Preventable medical errors in hospital settings are the third leading cause of deaths in the United States. However, less is known about harm that occurs in patients in outpatient settings, where the majority of care is delivered. We do not know the likelihood that a patient sitting in a dentist chair will experience harm. Additionally, we do not know if patients of certain race, age, sex, or socioeconomic status disproportionately experience iatrogenic harm. METHODS: We initiated the Dental Practice Study (DPS) with the aim of determining the frequency and types of adverse events (AEs) that occur in dentistry on the basis of retrospective chart audit...
December 5, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/29189044/desvenlafaxine-versus-placebo-in-a-fluoxetine-referenced-study-of-children-and-adolescents-with-major-depressive-disorder
#9
Karen L Weihs, William Murphy, Richat Abbas, Deborah Chiles, Richard D England, Sara Ramaker, Dalia B Wajsbrot
OBJECTIVES: To evaluate the short-term efficacy and safety of desvenlafaxine (25-50 mg/d) compared with placebo in children and adolescents with major depressive disorder (MDD). METHODS: Outpatient children (7-11 years) and adolescents (12-17 years) who met DSM-IV-TR criteria for MDD and had screening and baseline Children's Depression Rating Scale-Revised (CDRS-R) total scores >40 were randomly assigned to 8-week treatment with placebo, desvenlafaxine (25, 35, or 50 mg/d based on baseline weight), or fluoxetine (20 mg/d)...
November 30, 2017: Journal of Child and Adolescent Psychopharmacology
https://www.readbyqxmd.com/read/29187242/statistical-analysis-plan-for-the-eurohyp-1-trial-european-multicentre-randomised-phase-iii-clinical-trial-of-the-therapeutic-hypothermia-plus-best-medical-treatment-versus-best-medical-treatment-alone-for-acute-ischaemic-stroke
#10
Per Winkel, Philip M Bath, Christian Gluud, Jane Lindschou, H Bart van der Worp, Malcolm R Macleod, Istvan Szabo, Isabelle Durand-Zaleski, Stefan Schwab
BACKGROUND: Cooling may reduce infarct size and improve neurological outcomes in patients with ischaemic stroke. In phase II trials, cooling awake patients with ischaemic stroke has been shown to be feasible and safe, but the effects in functional outcomes has not yet been investigated in an adequately sized randomised clinical trial. METHODS/DESIGN: The EuroHYP-1 trial is a multinational, randomised, superiority phase III clinical trial with masked outcome assessment testing the benefits and harms of therapeutic cooling in awake adult patients with acute ischaemic stroke...
November 29, 2017: Trials
https://www.readbyqxmd.com/read/29183678/-description-of-contributing-factors-in-adverse-events-related-to-patient-safety-and-their-preventability
#11
María Mercedes Guerra-García, Beatriz Campos-Rivas, Alexandra Sanmarful-Schwarz, Alicia Vírseda-Sacristán, M Aránzazu Dorrego-López, Ángeles Charle-Crespo
OBJECTIVE: To assess the extent of healthcare related adverse events (AEs), their effect on patients, and their seriousness. To analyse the factors leading to the development of AEs, their relationship with the damage caused, and their degree of preventability. DESIGN: Retrospective descriptive study. LOCATION: Porriño, Pontevedra, Spain, Primary Care Service, from January-2014 to April-2016. PARTICIPANTS AND/OR CONTEXT: Reported AEs were entered into the Patient Safety Reporting and Learning System (SiNASP)...
November 25, 2017: Atencion Primaria
https://www.readbyqxmd.com/read/29176495/soft-factors-smooth-transport-the-role-of-safety-climate-and-team-processes-in-reducing-adverse-events-during-intrahospital-transport-in-intensive-care
#12
Markus Latzke, Michael Schiffinger, Dominik Zellhofer, Johannes Steyrer
BACKGROUND: Intrahospital patient transports (IHTs) in intensive care involve an appreciable risk of adverse events (AEs). Research on determinants of AE occurrence during IHT has hitherto focused on patient, transport, and intensive care unit (ICU) characteristics. By contrast, the role of "soft" factors, although arguably relevant for IHTs and a topic of interest in general health care settings, has not yet been explored. PURPOSE: The study aims at examining the effect of safety climate and team processes on the occurrence of AE during IHT and whether team processes mediate the effect of safety climate...
November 15, 2017: Health Care Management Review
https://www.readbyqxmd.com/read/29172979/pharmacovigilance-of-biologics-in-a-multisource-environment
#13
Sreedhar Sagi, Hillel P Cohen, Gillian R Woollett
It is important that systems are in place to ensure that appropriate and comprehensive records are kept for use of all medications. It is fundamental to an effective pharmacovigilance system that patient medical records contain sufficient information to identify which medication has been prescribed, when it was administered, and at what dose. The availability of biologics from multiple sponsors has raised questions by some health care providers about the ability of current pharmacovigilance systems to trace specific biologics...
December 2017: Journal of Managed Care & Specialty Pharmacy
https://www.readbyqxmd.com/read/29166828/nurses-systems-thinking-competency-medical-error-reporting-and-the-occurrence-of-adverse-events-a-cross-sectional-study
#14
Jee-In Hwang, Hyeoun-Ae Park
BACKGROUND: Healthcare professionals' systems thinking is emphasized for patient safety. AIMS: To report nurses' systems thinking competency, and its relationship with medical error reporting and the occurrence of adverse events. DESIGN: A cross-sectional survey using a previously validated Systems Thinking Scale (STS), was conducted. METHODS: Nurses from two teaching hospitals were invited to participate in the survey...
November 30, 2017: Contemporary Nurse
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
#15
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
#16
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
#17
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
#18
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
#19
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
#20
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
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