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Patient safety, human error

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https://www.readbyqxmd.com/read/28520711/inhalational-chlorine-injuries-at-public-aquatic-venues-california-2008-2015
#1
Jason A Wilken, Michele DiMaggio, Matthew Kaufmann, Kevin O'Connor, Svetlana Smorodinsky, Christina Armatas, Tracy Barreau, Richard Kreutzer, Lino Ancheta
In June 2015, personnel from California's Contra Costa Health Services Environmental Health and Hazardous Materials (hazmat) divisions were alerted to a possible chemical release at a swimming pool in an outdoor municipal water park. Approximately 50 bathers were in the pool when symptoms began; 34 (68%) experienced vomiting, coughing, or eye irritation. Among these persons, 17 (50%) were treated at the scene by Contra Costa's Emergency Medical Services (EMS) and released, and 17 (50%) were transported to local emergency departments; five patients also were evaluated later at an emergency department or by a primary medical provider...
May 19, 2017: MMWR. Morbidity and Mortality Weekly Report
https://www.readbyqxmd.com/read/28470132/value-based-hr-practices-i-deals-and-clinical-error-control-with-csr-as-a-moderator
#2
Tuan Luu, Chris Rowley, Sununta Siengthai, Vo Thanh Thao
Purpose Notwithstanding the rising magnitude of system factors in patient safety improvement, "human factors" such as idiosyncratic deals (i-deals) which also contribute to the adjustment of system deficiencies should not be neglected. The purpose of this paper is to investigate the role of value-based HR practices in catalyzing i-deals, which then influence clinical error control. The research further examines the moderating role of corporate social responsibility (CSR) on the effect of value-based HR practices on i-deals...
May 8, 2017: International Journal of Health Care Quality Assurance
https://www.readbyqxmd.com/read/28437161/randomized-phase-iii-trial-of-trastuzumab-plus-capecitabine-with-or-without-pertuzumab-in-patients-with-human-epidermal-growth-factor-receptor-2-positive-metastatic-breast-cancer-who-experienced-disease-progression-during-or-after-trastuzumab-based-therapy
#3
Ander Urruticoechea, Mohammed Rizwanullah, Seock-Ah Im, Antonio Carlos Sánchez Ruiz, István Láng, Gianluca Tomasello, Hannah Douthwaite, Tanja Badovinac Crnjevic, Sarah Heeson, Jennifer Eng-Wong, Montserrat Muñoz
Purpose To assess the efficacy and safety of trastuzumab plus capecitabine with or without pertuzumab in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer who experienced disease progression during or after trastuzumab-based therapy and received a prior taxane. Patients and Methods Patients were randomly assigned to arm A: trastuzumab 8 mg/kg → 6 mg/kg once every 3 weeks plus capecitabine 1,250 mg/m(2) twice a day (2 weeks on, 1 week off, every 3 weeks); or arm B: pertuzumab 840 mg → 420 mg once every 3 weeks plus trastuzumab at the same dose and schedule as arm A plus capecitabine 1,000 mg/m(2) on the same schedule as arm A...
April 24, 2017: Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology
https://www.readbyqxmd.com/read/28418101/effect-of-an-electronic-medication-administration-record-application-on-patient-safety
#4
Noelia Vicente Oliveros, Teresa Gramage Caro, Covadonga Pérez Menendez-Conde, Ana María Álvarez-Díaz, Sagrario Martín-Aragón Álvarez, Teresa Bermejo Vicedo, Eva Delgado Silveira
RATIONALE, AIMS, AND OBJECTIVES: To evaluate the effect of an electronic medication administration record (eMAR) application on the rate of medication errors in medication administration recording (ME-MAR). METHODS: A before-and-after, quasiexperimental study was conducted in a university hospital that implemented the eMAR application in March 2014. Data collection was conducted in April 2012 (pre-) and June 2014 (post-) by two pharmacists. The ME-MARs were analysed by the staff involved to identify their cause...
April 18, 2017: Journal of Evaluation in Clinical Practice
https://www.readbyqxmd.com/read/28417303/paediatric-in-patient-prescribing-errors-in-malaysia-a-cross-sectional-multicentre-study
#5
Teik Beng Khoo, Jing Wen Tan, Hoong Phak Ng, Chong Ming Choo, Intan Nor Chahaya Bt Abdul Shukor, Siao Hean Teh
Background There is a lack of large comprehensive studies in developing countries on paediatric in-patient prescribing errors in different settings. Objectives To determine the characteristics of in-patient prescribing errors among paediatric patients. Setting General paediatric wards, neonatal intensive care units and paediatric intensive care units in government hospitals in Malaysia. Methods This is a cross-sectional multicentre study involving 17 participating hospitals. Drug charts were reviewed in each ward to identify the prescribing errors...
April 17, 2017: International Journal of Clinical Pharmacy
https://www.readbyqxmd.com/read/28410711/failure-modes-and-effects-analysis-of-bilateral-same-day-cataract-surgery
#6
Neal H Shorstein, Carol Lucido, James Carolan, Liyan Liu, Geraldine Slean, Lisa J Herrinton
PURPOSE: To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING: Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN: Retrospective cohort study. METHODS: Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry...
March 2017: Journal of Cataract and Refractive Surgery
https://www.readbyqxmd.com/read/28394204/medication-adherence-staying-within-the-boundaries-of-safety
#7
Robin Sue Mickelson, Richard J Holden
An important domain of patient safety is the management of medications in home and community settings by patients and their caregiving network. This study applied human factors/ergonomics theories and methods to data about medication adherence collected from 61 patients with heart failure accompanied by 31 informal caregivers living in the US. Seventy non-adherence events were identified, described, and analysed for performance shaping factors. Half were classified as errors and half as violations. Performance shaping factors included elements of the person or team (e...
April 10, 2017: Ergonomics
https://www.readbyqxmd.com/read/28364581/self-reported-confidence-in-patient-safety-knowledge-among-australian-undergraduate-nursing-students-a-multi-site-cross-sectional-survey-study
#8
Kim Usher, Cindy Woods, Glenda Parmenter, Marie Hutchinson, Judy Mannix, Tamara Power, Wendy Chaboyer, Sharon Latimer, Jane Mills, Lesley Siegloff, Debra Jackson
BACKGROUND: Patient safety is critical to the provision of quality health care and thus is an essential component of nurse education. OBJECTIVE: To describe first, second and third year Australian undergraduate nursing students' confidence in patient safety knowledge acquired in the classroom and clinical settings across the three years of the undergraduate nursing program. DESIGN: A cross-sectional online survey conducted in 2015. SETTING: Seven Australian universities with campuses across three states (Queensland, New South Wales, South Australia)...
March 25, 2017: International Journal of Nursing Studies
https://www.readbyqxmd.com/read/28338437/contralateral-peripheral-neurotization-for-a-hemiplegic-hindlimb-after-central-neurological-injury
#9
Mou-Xiong Zheng, Xu-Yun Hua, Su Jiang, Yan-Qun Qiu, Yun-Dong Shen, Wen-Dong Xu
OBJECTIVE Contralateral peripheral neurotization surgery has been successfully applied to rescue motor function of the hemiplegic upper extremity in patients with central neurological injury (CNI). It may contribute to strengthened neural pathways between the contralesional cortex and paretic limbs. However, the effect of this surgery in the lower extremities remains unknown. In the present study the authors explored the effectiveness and safety of contralateral peripheral neurotization in treating a hemiplegic lower extremity following CNI in adult rats...
March 24, 2017: Journal of Neurosurgery
https://www.readbyqxmd.com/read/28325209/-to-err-is-human-but-to-not-put-processes-in-place-to-avoid-errors-from-becoming-fatal-is-inhumane-5th-international-summit-of-the-patient-safety-movement-psm-california-usa-2017
#10
https://www.readbyqxmd.com/read/28257288/root-cause-analyses-of-reported-adverse-events-occurring-during-gastrointestinal-scope-and-tube-placement-procedures-in-the-veterans-health-association
#11
Christina Soncrant, Peter D Mills, Julia Neily, Douglas E Paull, Robin R Hemphill
OBJECTIVE: This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur. METHODS: This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database...
March 3, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28248749/medication-safety-in-two-intensive-care-units-of-a-community-teaching-hospital-after-electronic-health-record-implementation-sociotechnical-and-human-factors-engineering-considerations
#12
Pascale Carayon, Tosha B Wetterneck, Randi Cartmill, Mary Ann Blosky, Roger Brown, Peter Hoonakker, Robert Kim, Sandeep Kukreja, Mark Johnson, Bonnie L Paris, Kenneth E Wood, James M Walker
OBJECTIVE: The aim of the study was to assess the impact of Electronic Health Record (EHR) implementation on medication safety in two intensive care units (ICUs). METHODS: Using a prospective pre-post design, we assessed 1254 consecutive admissions to two ICUs before and after an EHR implementation. Each medication event was evaluated with regard to medication error (error type, medication-management stage) and impact on patient (severity of potential or actual harm)...
February 28, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28219432/personalized-heterogeneous-deformable-model-for-fast-volumetric-registration
#13
Weixin Si, Xiangyun Liao, Qiong Wang, Pheng Ann Heng
BACKGROUND: Biomechanical deformable volumetric registration can help improve safety of surgical interventions by ensuring the operations are extremely precise. However, this technique has been limited by the accuracy and the computational efficiency of patient-specific modeling. METHODS: This study presents a tissue-tissue coupling strategy based on penalty method to model the heterogeneous behavior of deformable body, and estimate the personalized tissue-tissue coupling parameters in a data-driven way...
February 20, 2017: Biomedical Engineering Online
https://www.readbyqxmd.com/read/28196568/human-milk-management-redesign-improving-quality-and-safety-and-reducing-neonatal-intensive-care-unit-nurse-stress
#14
Margaret Doyle Settle, Amanda Bulette Coakley, Christine Donahue Annese
Human milk provides superior nutritional value for infants in the neonatal intensive care unit and is the enteral feeding of choice. Our hospital used the system engineering initiative for patient safety model to evaluate the human milk management system in our neonatal intensive care unit. Nurses described the previous process in a negative way, fraught with opportunities for error, increased stress for nurses, and the need to be away from the bedside and their patients. The redesigned process improved the quality and safety of human milk management and created time for the nurses to spend with their patients...
February 1, 2017: Creative Nursing
https://www.readbyqxmd.com/read/28193619/improving-specialist-drug-prescribing-in-primary-care-using-task-and-error-analysis-an-observational-study
#15
Narinder Chana, Talya Porat, Cate Whittlesea, Brendan Delaney
BACKGROUND: Electronic prescribing has benefited from computerised clinical decision support systems (CDSSs); however, no published studies have evaluated the potential for a CDSS to support GPs in prescribing specialist drugs. AIM: To identify potential weaknesses and errors in the existing process of prescribing specialist drugs that could be addressed in the development of a CDSS. DESIGN AND SETTING: Semi-structured interviews with key informants followed by an observational study involving GPs in the UK...
March 2017: British Journal of General Practice: the Journal of the Royal College of General Practitioners
https://www.readbyqxmd.com/read/28192533/improving-medication-safety-development-and-impact-of-a-multivariate-model-based-strategy-to-target-high-risk-patients
#16
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/28186187/factors-associated-with-aberrant-imprint-methylation-and-oligozoospermia
#17
Norio Kobayashi, Naoko Miyauchi, Nozomi Tatsuta, Akane Kitamura, Hiroaki Okae, Hitoshi Hiura, Akiko Sato, Takafumi Utsunomiya, Nobuo Yaegashi, Kunihiko Nakai, Takahiro Arima
Disturbingly, the number of patients with oligozoospermia (low sperm count) has been gradually increasing in industrialized countries. Epigenetic alterations are believed to be involved in this condition. Recent studies have clarified that intrinsic and extrinsic factors can induce epigenetic transgenerational phenotypes through apparent reprogramming of the male germ line. Here we examined DNA methylation levels of 22 human imprinted loci in a total of 221 purified sperm samples from infertile couples and found methylation alterations in 24...
February 10, 2017: Scientific Reports
https://www.readbyqxmd.com/read/28185075/paediatric-patient-safety-and-the-need-for-aviation-black-box-thinking-to-learn-from-and-prevent-medication-errors
#18
REVIEW
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/28179154/managing-the-patient-identification-crisis-in-healthcare-and-laboratory-medicine
#19
REVIEW
Giuseppe Lippi, Camilla Mattiuzzi, Chiara Bovo, Emmanuel J Favaloro
Identification errors have emerged as a critical issue in health care, as testified by the ample scientific literature on this argument. Despite available evidence suggesting that the frequency of misidentification in vitro laboratory diagnostic testing may be relatively low compared to that of other laboratory errors (i.e., usually comprised between 0.01 and 0.1% of all specimens received), the potential adverse consequences remain particularly worrying, wherein 10-20% of these errors not only would translate into serious harm for the patient, but may also erode considerable human and economic resources, so that the entire healthcare system should be re-engineered to act proactively and limiting the burden of this important problem...
February 5, 2017: Clinical Biochemistry
https://www.readbyqxmd.com/read/28099286/multicenter-study-validating-accuracy-of-a-continuous-respiratory-rate-measurement-derived-from-pulse-oximetry-a-comparison-with-capnography
#20
Sergio D Bergese, Michael L Mestek, Scott D Kelley, Robert McIntyre, Alberto A Uribe, Rakesh Sethi, James N Watson, Paul S Addison
BACKGROUND: Intermittent measurement of respiratory rate via observation is routine in many patient care settings. This approach has several inherent limitations that diminish the clinical utility of these measurements because it is intermittent, susceptible to human error, and requires clinical resources. As an alternative, a software application that derives continuous respiratory rate measurement from a standard pulse oximeter has been developed. We sought to determine the performance characteristics of this new technology by comparison with clinician-reviewed capnography waveforms in both healthy subjects and hospitalized patients in a low-acuity care setting...
April 2017: Anesthesia and Analgesia
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