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medication error

Adewole S Adamson, Elizabeth A Suarez, April R Gorman
Importance: Prescription underuse is associated with poorer clinical outcomes. A significant proportion of underuse is owing to primary nonadherence, defined as the rate at which patients fail to fill and pick up new prescriptions. Although electronic prescribing increases coordination of care and decreases errors, its effect on primary nonadherence is less certain. Objectives: To analyze factors associated with primary nonadherence to dermatologic medications and study whether electronic prescribing affects rates of primary nonadherence...
October 26, 2016: JAMA Dermatology
Carmela Rinaldi, Fabrizio Leigheb, Angelo Di Dio, Kris Vanhaecht, Chiara Donnarumma, Massimiliano Panella
A second victim has been defined as "a healthcare worker involved in an unanticipated adverse patient event, medical error and/or a patient related-injury who becomes victimized in the sense that the worker is traumatized by the event". The aim of the present research study was to assess the "second victim" phenomenon in Italy. Fifty interviews were conducted with different health care professionals previously involved in medical errors. All study participants clearly remembered the event. Support obtained by second victims was poor and inefficient...
July 2016: Igiene e Sanità Pubblica
Scott Monteith, Tasha Glenn
Automated decision-making by computer algorithms based on data from our behaviors is fundamental to the digital economy. Automated decisions impact everyone, occurring routinely in education, employment, health care, credit, and government services. Technologies that generate tracking data, including smartphones, credit cards, websites, social media, and sensors, offer unprecedented benefits. However, people are vulnerable to errors and biases in the underlying data and algorithms, especially those with mental illness...
December 2016: Current Psychiatry Reports
Noa Geffen, Michael Mimouni, Mark Sherwood, Ehud I Assia
PURPOSE: To evaluate the efficacy and safety of CO2 Laser-assisted Sclerectomy Surgery (CLASS) in primary and pseudoexfoliative open-angle glaucoma. MATERIALS AND METHODS: Single-arm, open-label study included data from 9 medical centers located in 7 countries. Subjects underwent nonpenetrating CLASS procedure with a CO2 laser system (IOPtiMate). Intraocular pressure (IOP) and number of medications were measured at baseline, 1, 2, 4, and 6 weeks, and 3, 6, 12, 24, and 36 months...
October 25, 2016: Journal of Glaucoma
Geoffrey R Norman, Sandra D Monteiro, Jonathan Sherbino, Jonathan S Ilgen, Henk G Schmidt, Sylvia Mamede
Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2). Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear. Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning. Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases...
October 25, 2016: Academic Medicine: Journal of the Association of American Medical Colleges
L A Bitzer, K Neumann, N Benson, R Schmechel
Super-resolution (SR) is a technique used in digital image processing to overcome the resolution limitation of imaging systems. In this process, a single high resolution image is reconstructed from multiple low resolution images. SR is commonly used for CCD and CMOS (Complementary Metal-Oxide-Semiconductor) sensor images, as well as for medical applications, e.g., magnetic resonance imaging. Here, we demonstrate that super-resolution can be applied with scanning light stimulation (LS) systems, which are common to obtain space-resolved electro-optical parameters of a sample...
September 2016: Review of Scientific Instruments
Edward Ivor Broughton, Lani Marquez
There is little evidence to direct health systems toward providing efficient interventions to address medical errors, defined as an unintended act of omission or commission or one not executed as intended that may or may not cause harm to the patient but does not achieve its intended outcome. We believe that lack of guidance on what is the most efficient way to reduce medical errors and improve the quality of health-care limits the scale-up of health system improvement interventions. Challenges to economic evaluation of these interventions include defining and implementing improvement interventions in different settings with high fidelity, capturing all of the positive and negative effects of the intervention, using process measures of effectiveness rather than health outcomes, and determining the full cost of the intervention and all economic consequences of its effects...
2016: Frontiers in Public Health
Rebecca Ruch-Gallie, Heather Weir, Lori R Kogan
Cognitive functioning is often compromised with increasing levels of stress and fatigue, both of which are often experienced by veterinarians. Many high-stress fields have implemented checklists to reduce human error. The use of these checklists has been shown to improve the quality of medical care, including adherence to evidence-based best practices and improvement of patient safety. Although it has been recognized that veterinary medicine would likely demonstrate similar benefits, there have been no published studies to date evaluating the use of checklists for improving quality of care in veterinary medicine...
October 25, 2016: Journal of Veterinary Medical Education
Jonila Cyco Gabrani, Wendy Knibb, Elizana Petrela, Adrian Hoxha, Adriatik Gabrani
PURPOSE: The purpose of this study was to determine the safety attitudes of specialist physicians (SPs), general physicians (GPs), and nurses in primary care in Albania. DESIGN: The study was cross-sectional. It involved the SPs, GPs, and nurses from five districts in Albania. A demographic questionnaire and the adapted Safety Attitudes Questionnaire (SAQ)-Long Ambulatory Version A was used to gather critical information regarding the participant's profile, perception of management, working conditions, job satisfaction, stress recognition, safety climate, and perceived teamwork...
October 25, 2016: Journal of Nursing Scholarship
Kun Zhong, Wei Wang, Chuanbao Zhang, Falin He, Shuai Yuan, Zhiguo Wang
BACKGROUND: Clinical laboratory tests are important for clinicians to make diagnostic decisions, but discrepancies may directly lead to incorrect diagnosis. We would like to introduce some statistical methods to evaluate the comparability of chemistry analytes while comparing the performances of different measurement systems. METHODS: We used a panel of 10 fresh-frozen single donation serum samples to assess assays for the measurement of glucose and other 13 analytes...
2016: SpringerPlus
Flavio Egger, Federica Targa, Ivan Unterholzner, Russell P Grant, Markus Herrmann, Christian J Wiedermann
Non-vitamin K oral anticoagulant (NOAC) therapy may be inappropriate if prescription was incorrect, the patient's physiological parameters change, or interacting concomitant medications are erroneously added. The aim of this report was to illustrate inappropriate NOAC prescription in a 78-year-old woman with non-valvular atrial fibrillation and borderline renal dysfunction who was switched from warfarin to rivaroxaban and subsequently developed bruising with hemorrhagic shock and acute on chronic renal failure...
August 8, 2016: Clinics and Practice
Jason Kwah, Jennifer Weintraub, Robert Fallar, Jonathan Ripp
BACKGROUND : Burnout is a common issue in internal medicine residents, and its impact on medical errors and professionalism is an important subject of investigation. OBJECTIVE : To evaluate differences in medical errors and professionalism in internal medicine residents with and without burnout. METHODS : A single institution observational cohort study was conducted between June 2011 and July 2012. Burnout was measured using the Maslach Burnout Inventory to generate subscores for the following 3 domains: emotional exhaustion, depersonalization, and sense of personal accomplishment...
October 2016: Journal of Graduate Medical Education
(no author information available yet)
Checklists are used in medical and nonmedical settings as cognitive aids to ensure that users complete all the items associated with a particular task. They are ideal for tasks with many steps, for tasks performed under stressful circumstances, or for reminding people to perform tasks that they are not routinely accustomed to doing. In medicine, they are ideal for promoting standardized processes of care in situations in which variation in practice may increase patient risk and the chance of medical errors...
November 2016: Obstetrics and Gynecology
(no author information available yet)
Checklists are used in medical and nonmedical settings as cognitive aids to ensure that users complete all the items associated with a particular task. They are ideal for tasks with many steps, for tasks performed under stressful circumstances, or for reminding people to perform tasks that they are not routinely accustomed to doing. In medicine, they are ideal for promoting standardized processes of care in situations in which variation in practice may increase patient risk and the chance of medical errors...
November 2016: Obstetrics and Gynecology
Duy Dao, S M A Salehizadeh, Yeon Noj, Jo Woon Chong, Chae Cho, Dave Mcmanus, Chad E Darling, Yitzhak Mendelson, Ki H Chon
Motion and noise artifacts (MNAs) impose limits on the usability of the photoplethysmogram (PPG), particularly in the context of ambulatory monitoring. MNAs can distort PPG, causing erroneous estimation of physiological parameters such as heart rate (HR) and arterial oxygen saturation (SpO2). In this study we present a novel approach, "TifMA," based on using the Time-frequency spectrum of PPG to first detect the MNA-corrupted data and next discard the non-usable part of the corrupted data. The term "non-usable" refers to segments of PPG data from which the HR signal cannot be recovered accurately...
October 21, 2016: IEEE Journal of Biomedical and Health Informatics
R M Paredes Esteban, J I Garrido Pérez, A Ruiz Palomino, G Guerrero Peña, F Vázquez Rueda, M J Berenguer García, R Miñarro Del Moral, M Tejedor Fernández
OBJECTIVES: In 2014 our department starts to apply the PatientSafety Strategic in Pediatric Surgery. Our aim is to describe the results obtained. METHODS: For the measurement of adverse events (AE) we used a modification of the Global Trigger Tool of the Institute for Healthcare Improvement. Population analysed: patients undergoing surgery with hospitalization. On a monthly basis, audits of the medical records of 12 patients discharged in the prior week of the assessment were performed...
April 20, 2016: Cirugía Pediátrica: Organo Oficial de la Sociedad Española de Cirugía Pediátrica
J R Ryder, A Kaizer, K D Rudser, A Gross, A S Kelly, C K Fox
Phentermine is the most widely prescribed obesity medication in adults, yet studies of its use in the pediatric population are limited. We conducted a retrospective chart review of adolescents with obesity treated in a pediatric weight management clinic to examine the weight loss effectiveness of phentermine added to standard of care lifestyle modification therapy (SOC) versus SOC alone. All patients receiving phentermine plus SOC (n=25) were matched with a comparison group receiving only SOC (n=274). Differences at 1, 3, and 6 months were evaluated using generalized estimated equations adjusting for age, sex, and baseline body mass index (BMI) and robust variance standard error estimates for confidence intervals and P-values...
October 24, 2016: International Journal of Obesity: Journal of the International Association for the Study of Obesity
Vance G Nielsen, Samata R Paidy, Camron A Meek, Tiffany K Thornton, Scott D Lick
We present a case of a patient undergoing aortic valve replacement being inadvertently administered 5000 U of bovine thrombin instead of heparin for anticoagulation for cardiopulmonary bypass. The labeling error was made within the operating room pharmacy. The key to survival of this patient was a rapid diagnosis, administration of antithrombin and heparin, and removal of cardiac and great vessel thrombi. It is recommended that point of care anesthesia providers `prepare heparin for cardiopulmonary bypass anticoagulation, as thrombin is not used in anesthetic practice and is not contained within anesthesia cabinet medication drawers...
October 22, 2016: International Journal of Legal Medicine
Shady A Rehim, Stephanie DeMoor, Richard Olmsted, Daniel L Dent, Jessica Parker-Raley
BACKGROUND: Hospital action teams comprise interdisciplinary health care providers working simultaneously to treat critically ill patients. Assessments designed to evaluate communication effectiveness or "nontechnical" performance of these teams are essential to minimize medical errors and improve team productivity. Although multiple communication tools are available, the characteristics and psychometric validity of these instruments have yet to be systematically compared. OBJECTIVE: To identify assessments used to evaluate the communication or "nontechnical" performance of hospital action teams and summarize evidence to develop and validate these instruments...
October 19, 2016: Journal of Surgical Education
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
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