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Reporting errors

Sergio Susmallian, Benjamin Raskin, Royi Barnea
INTRODUCTION: Retained surgical sponge or other items in patients' bodies happens more frequently than is reported. Healthcare personnel can forget to remove textile material or instruments during complicated, extended, or emergency surgery. In addition, changes in the operating team can influence the occurrence of such errors. PRESENTATION OF CASE: We present a case with a symptomatic gossypiboma nine years after a previous cesarean section. A 34-year-old woman was admitted to the emergency room having experienced abdominal pain and fever for the previous month...
October 14, 2016: International Journal of Surgery Case Reports
Nibal R Chamoun, Rony Zeenny, Hanine Mansour
Background Pharmacists' involvement in patient care has improved the quality of care and reduced medication errors. However, this has required a lot of work that could not have been accomplished without documentation of interventions. Several means of documenting errors have been proposed in the literature but without a consistent comprehensive process. Recently, the American College of Clinical Pharmacy (ACCP) recognized that pharmacy practice lacks a consistent process for direct patient care and discussed several options for a pharmaceutical care plan, essentially encompassing medication therapy assessment, development and implementation of a pharmaceutical care plan and finally evaluation of the outcome...
October 21, 2016: International Journal of Clinical Pharmacy
C H Wong, T R Tan, H Y Heng Hy, T Ramesh, P W Ting, W S Lee, C L Teng, N Sivalingam, K K Tan
INTRODUCTION: Open disclosure is poorly understood in Malaysia but is an ethical and professional responsibility. The objectives of this study were to determine: (1) the perception of parents regarding the severity of medical error in relation to medication use or diagnosis; (2) the preference of parents for information following the medical error and its relation to severity; and (3) the preference of parents with regards to disciplinary action, reporting, and legal action. METHODS: We translated and contextualised a questionnaire developed from a previous study...
August 2016: Medical Journal of Malaysia
Auke B C Otten, Alphons P M Stassen, Michiel Adriaens, Mike Gerards, Richard G J Dohmen, Adriana J Timmer, Sabina J V Vanherle, Rick Kamps, Iris B W Boesten, Jo M Vanoevelen, Marc Muller, Bert Smeets
Of all pathogenic mitochondrial DNA (mtDNA) mutations in humans, ~25% is de novo, although the occurrence in oocytes has never been directly assessed. We used next generation sequencing to detect point mutations directly in the mtDNA of 3-15 individual mature oocytes and three somatic tissues from eight zebrafish females. Various statistical and biological filters allowed reliable detection of de novo variants with heteroplasmy ≥1.5%. In total, we detected 38 de novo base substitutions, but no insertions or deletions...
October 21, 2016: Genetics
Gary C Packard
Recent reports indicate that field metabolic rates (FMRs) of mammals conform to a pattern of complex allometry in which the exponent in a simple, two-parameter power equation increases steadily as a dependent function of body mass. The reports were based, however, on indirect analyses performed on logarithmic transformations of the original data. I re-examined values for FMR and body mass for 114 species of mammal by the conventional approach to allometric analysis (to illustrate why the approach is unreliable) and by linear and nonlinear regression on untransformed variables (to illustrate the power and versatility of newer analytical methods)...
October 19, 2016: Comparative Biochemistry and Physiology. Part A, Molecular & Integrative Physiology
Manisha Balwani, Preeti Singh, Anju Seth, Ekta Malik Debnath, Hetanshi Naik, Dana Doheny, Brenden Chen, Makiko Yasuda, Robert J Desnick
Acute Intermittent Porphyria (AIP), an autosomal dominant inborn error of heme metabolism, typically presents in adulthood, most often in women in the reproductive age group. There are limited reports on the clinical presentation in children, and in contrast to the adults, most of the reported pediatric cases are male. While acute abdominal pain is the most common presenting symptom in children, seizures are commonly seen and may precede the diagnosis of AIP. As an example, we report a 9year old developmentally normal pre-pubertal boy who presented with acute abdominal pain, vomiting and constipation followed by hyponatremia, seizures, weakness and neuropathy...
October 15, 2016: Molecular Genetics and Metabolism
Michael X Repka, Trevano W Dean, Elizabeth L Lazar, Kimberly G Yen, Phoebe D Lenhart, Sharon F Freedman, Denise Hug, Bahram Rahmani, Serena X Wang, Raymond T Kraker, David K Wallace
OBJECTIVE: To describe baseline characteristics, initial postoperative refractive errors, operative complications, and magnitude of the intraocular lens (IOL) prediction error for refractive outcome in children undergoing lensectomy largely in North America. DESIGN: Prospective registry study of children from birth to <13 years of age who underwent lensectomy for any reason within 45 days preceding enrollment. PARTICIPANTS: Total of 1266 eyes of 994 children; 49% female and 59% white...
October 18, 2016: Ophthalmology
Hardeep Singh, Mark L Graber, Timothy P Hofer
Timely and accurate diagnosis is foundational to good clinical practice and an essential first step to achieving optimal patient outcomes. However, a recent Institute of Medicine report concluded that most of us will experience at least one diagnostic error in our lifetime. The report argues for efforts to improve the reliability of the diagnostic process through better measurement of diagnostic performance. The diagnostic process is a dynamic team-based activity that involves uncertainty, plays out over time, and requires effective communication and collaboration among multiple clinicians, diagnostic services, and the patient...
October 20, 2016: Journal of Patient Safety
David C Classen, William Munier, Nancy Verzier, Noel Eldridge, David Hunt, Mark Metersky, Chesley Richards, Yun Wang, P Jeffrey Brady, Amy Helwig, James Battles
The explicit declaration in the landmark 1999 Institute of Medicine report "To Err Is Human" that, in the United States, 44,000 to 98,000 patients die each year as a consequence of "medical errors" gave widespread validation to the magnitude of the patient safety problem and catalyzed a number of U.S. federal government programs to measure and improve the safety of the national healthcare system. After more than 10 years, one of those federal programs, the Medicare Patient Safety Monitoring System (MPSMS), has reached a level of maturity and stability that has made it useful for the consistent measurement of the safety of inpatient care...
October 20, 2016: Journal of Patient Safety
Leonardo Koerich, André Weissheimer, Luciane Macedo de Menezes, Steven J Lindauer
OBJECTIVE: To evaluate the precision and reproducibility of a protocol to perform rapid voxel-based superimposition of the mandible in growing patients using CBCT. MATERIALS AND METHODS: The sample comprised two cone-beam computed tomography scans taken at least 1 year apart from each of 24 growing patients. Voxel-based superimposition was performed by two examiners independently. The internal part of the symphysis extending to the first molar was used as the reference...
October 21, 2016: Angle Orthodontist
Pierre E Affaticati, Shao-Bo Dai, Panwajee Payongsri, Helen C Hailes, Kai Tittmann, Paul A Dalby
The S385Y/D469T/R520Q variant of E. coli transketolase was evolved previously with three successive smart libraries, each guided by different structural, bioinformatical or computational methods. Substrate-walking progressively shifted the target acceptor substrate from phosphorylated aldehydes, towards a non-phosphorylated polar aldehyde, a non-polar aliphatic aldehyde, and finally a non-polar aromatic aldehyde. Kinetic evaluations on three benzaldehyde derivatives, suggested that their active-site binding was differentially sensitive to the S385Y mutation...
October 21, 2016: Scientific Reports
M E Pennant, R Mehta, P Moody, G Hackett, A Prentice, S J Sharp, R Lakshman
BACKGROUND: Endometrial biopsies are undertaken in premenopausal women with abnormal uterine bleeding but the risk of endometrial cancer or atypical hyperplasia is unclear. OBJECTIVES: To conduct a systematic literature review to establish the risk of endometrial cancer and atypical hyperplasia in premenopausal women with abnormal uterine bleeding. SEARCH STRATEGY: Search of PubMed, Embase and the Cochrane Library from database inception to August 2015...
October 20, 2016: BJOG: An International Journal of Obstetrics and Gynaecology
Maike C Herbort, Joram Soch, Torsten Wüstenberg, Kerstin Krauel, Maia Pujara, Michael Koenigs, Jürgen Gallinat, Henrik Walter, Stefan Roepke, Björn H Schott
Patients with borderline personality disorder (BPD) frequently exhibit impulsive behavior, and self-reported impulsivity is typically higher in BPD patients when compared to healthy controls. Previous functional neuroimaging studies have suggested a link between impulsivity, the ventral striatal response to reward anticipation, and prediction errors. Here we investigated the striatal neural response to monetary gain and loss anticipation and their relationship with impulsivity in 21 female BPD patients and 23 age-matched female healthy controls using functional magnetic resonance imaging (fMRI)...
2016: NeuroImage: Clinical
Bryan M Corbett, Charles O'Connell, Mallory A Boutin, Nabil I Fatayerji, Charles W Sauer
BACKGROUND Methylergonovine is an ergot alkaloid used to treat post-partum hemorrhage secondary to uterine atony. Mistaking methylergonovine for vitamin K with accidental administration to the neonate is a rare iatrogenic illness occurring almost exclusively in the delivery room setting. Complications of ergot alkaloids in neonates include respiratory depression, seizures, and death. CASE REPORT A term infant was inadvertently given 0.1 mg of methylergonovine intramuscularly in the right thigh. The error was only noted when the vial of medication was scanned, after administration, identifying it as methylergonovine rather than vitamin K...
October 21, 2016: American Journal of Case Reports
Tania Dukic Willstrand, Thomas Broberg, Helena Selander
BACKGROUND: To maintain the mobility of older people in later life, it is essential to sustain their autonomy; however, driving is a complex task, requiring a large range of visual, psychomotor and cognitive abilities. Subsequently, a key issue is to measure and evaluate the fitness to drive of older drivers. Several methods have been proposed, among them the useful field of view (UFOV) test. OBJECTIVE: The present study aimed to identify driving characteristics in older drivers and the relationship between the UFOV test and the on-road driving results...
October 21, 2016: Gerontology
Sook-Yee Chong, Oliver Röhrle
A satisfactorily fitted socket interacts dynamically with the stump in order to support body weight, transmit load effectively, enhance dynamic stability, and enable the control and stabilization of the residual limb. The internal dynamics occurring within a socket is important in determining optimal fit. Many measurement and imaging techniques, such as X-rays, have been utilized to investigate the movement of the residual femur within the stump during gait. However, due to associated health risks and costs, none of the current techniques have been extended to clinical prosthetics...
2016: PloS One
M V Fedulova, N V Vlasova, A N Shai
The authors report a case of the interstitial disease of the lungs revealed by a histological study that demonstrated intravital diagnostic faults in the patient in question. Moreover, a postmortem diagnostic error occurred; namely, the macroscopic study of the thoracic organs had shown the 0.5 cm long linear rupture of the adhesion in the right lung root region that was considered to be the cause of hemothorax and anemia of the internal organs which supposedly resulted in the patient's death. The definitive diagnosis of interstitial disease of the lungs was established based on the results of the histological study...
2016: Sudebno-meditsinskaia Ekspertiza
(no author information available yet)
Reports an error in "Does Reading a Single Passage of Literary Fiction Really Improve Theory of Mind? An Attempt at Replication" by Maria Eugenia Panero, Deena Skolnick Weisberg, Jessica Black, Thalia R. Goldstein, Jennifer L. Barnes, Hiram Brownell and Ellen Winner (Journal of Personality and Social Psychology, Advanced Online Publication, Sep 19, 2016, np). In the article, due to an error in stimulus construction, four items (three authors, one foil) were omitted from the ART presented to all participants tested by Research Group 1...
November 2016: Journal of Personality and Social Psychology
Hillary Anger Elfenbein, Daisung Jang, Sudeep Sharma, Jeffrey Sanchez-Burks
Emotional intelligence (EI) has captivated researchers and the public alike, but it has been challenging to establish its components as objective abilities. Self-report scales lack divergent validity from personality traits, and few ability tests have objectively correct answers. We adapt the Stroop task to introduce a new facet of EI called emotional attention regulation (EAR), which involves focusing emotion-related attention for the sake of information processing rather than for the sake of regulating one's own internal state...
October 20, 2016: Emotion
Xu Steven Xu, Min Yuan, Haitao Yang, Yan Feng, Jinfeng Xu, Jose Pinheiro
Covariate analysis based on population pharmacokinetics (PPK) is used to identify clinically relevant factors. The likelihood ratio test (LRT) based on nonlinear mixed effect model fits is currently recommended for covariate identification, whereas individual empirical Bayesian estimates (EBEs) are considered unreliable due to the presence of shrinkage. The objectives of this research were to investigate the type I error for LRT and EBE approaches, to confirm the similarity of power between the LRT and EBE approaches from a previous report and to explore the influence of shrinkage on LRT and EBE inferences...
October 19, 2016: AAPS Journal
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