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Medical error reporting

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https://www.readbyqxmd.com/read/28230580/the-patient-perspective-on-errors-in-cancer-care-results-of-a-cross-sectional-survey
#1
Mariko Carey, Allison W Boyes, Jamie Bryant, Heidi Turon, Tara Clinton-McHarg, Robert Sanson-Fisher
OBJECTIVE: The objective of this study was to explore medical oncology outpatients' perceived experiences of errors in their cancer care. METHODS: A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centers. Participants completed 2 paper-and-pencil questionnaires: an initial survey on demographic, disease and treatment characteristics upon recruitment; and a second survey on their experiences of errors in cancer care 1 month later...
February 22, 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28228099/impact-of-adding-additional-providers-to-resident-workload-and-the-resident-experience-on-a-medical-consultation-rotation
#2
Michele Fang, Eric Linson, Manish Suneja, Ethan F Kuperman
BACKGROUND: Excellence in Graduate Medical Education requires the right clinical environment with an appropriate workload where residents have enough patients to gain proficiency in medicine with optimal time for reflection. The Accreditation Council for Graduate Medical Education (ACGME) has focused more on work hours rather than workload; however, high resident workload has been associated with lower resident participation in education and fatigue-related errors. Recognizing the potential risks associated with high resident workload and being mindful of the costs of reducing resident workload, we sought to reduce residents' workload by adding an advanced practice provider (APP) to the surgical comanagement service (SCM) and study its effect on resident satisfaction and perceived educational value of the rotation...
February 22, 2017: BMC Medical Education
https://www.readbyqxmd.com/read/28227673/colorimetric-determinations-of-lithium-levels-in-drop-volumes-of-human-plasma-for-monitoring-patients-with-bipolar-mood-disorder
#3
M Qassem, M Hickey, P A Kyriacou, M Qassem, M Hickey, P A Kyriacou, M Qassem, M Hickey, P A Kyriacou
Lithium preparations are considered the most reliable form of mood stabilizing medication for patients with Bipolar disorder. Nevertheless, lithium is a toxic element and its therapeutic range is extremely narrow, with levels of 0.61.0 mEq considered normal, whereas levels above 1.5 mEq are toxic. Thus unfortunately, many patients reach toxic levels that lead to unnecessary complications. It is believed that personal monitoring of blood lithium levels would benefit patients taking lithium medication. Therefore, our aim is to develop a personal lithium blood level analyzer for patients with bipolar mood disorder, and we report here our initial results of a colorimetric-based method used to test drop-volumes of human plasma that had been spiked with lithium...
August 2016: Conference Proceedings: Annual International Conference of the IEEE Engineering in Medicine and Biology Society
https://www.readbyqxmd.com/read/28226033/effectiveness-of-pharmacovigilance-multifaceted-educational-intervention-related-to-the-knowledge-skills-and-attitudes-of-multidisciplinary-hospital-staff
#4
Fabiana Rossi Varallo, Cleopatra S Planeta, Patricia de Carvalho Mastroianni
OBJECTIVES: Most educational interventions in pharmacovigilance are designed to encourage physicians to report adverse drug reactions. However, multidisciplinary teams may play an important role in reporting drug-related problems. This study assessed the impact of a multifaceted educational intervention in pharmacovigilance on the knowledge, skills and attitudes of hospital professionals. METHOD: This prospective, open-label, non-randomized study was performed in a medium-complexity hospital in São Paulo, Brazil...
January 1, 2017: Clinics
https://www.readbyqxmd.com/read/28223040/red-blood-cell-exchange-as-an-approach-for-treating-a-case-of-severe-tacrolimus-overexposure
#5
Valentina Spallanzani, Lucia Bindi, Irene Bianco, Arianna Precisi, Paolo DeSimone, Alessandro Mazzoni, Gianni Biancofiore
Immunosuppressive medication dosing errors are not unfrequent and may present a number of challenges to transplant clinicians. Tacrolimus (TAC) is a widely used immunosuppressant with a narrow therapeutic index and potential severe side effects, including neurotoxicity and kidney injury. We herein report a case of 60-year-old woman who underwent deceased-donor liver transplantation at our center and due to inadvertent TAC overexposure was admitted to the Intensive Care Unit because of severe neurologic impairment, kidney injury and arterial hypotension...
February 2, 2017: Transfusion and Apheresis Science
https://www.readbyqxmd.com/read/28220252/long-term-surgical-outcomes-of-the-inverted-internal-limiting-membrane-flap-technique-in-highly-myopic-macular-hole-retinal-detachment
#6
Taiga Kinoshita, Yasutaka Onoda, Takatoshi Maeno
BACKGROUND: Pars plana vitrectomy (PPV) procedures are used for the surgical treatment of macular hole retinal detachment (MHRD) associated with high myopia. Re-detachment of the retina has been reported in MHRD associated with high myopia. Our aim was to evaluate the 1-year outcomes of vitrectomy, performed using an inverted internal limiting membrane (ILM) flap technique with gas tamponade, in five cases of MHRD associated with high myopia. METHODS: We performed a retrospective review of medical records of five consecutive cases of highly myopic MHRD...
February 20, 2017: Graefe's Archive for Clinical and Experimental Ophthalmology
https://www.readbyqxmd.com/read/28217303/three-years-evaluation-of-retained-foreign-bodies-after-surgery-in-iran
#7
Mohammad Zarenezhad, Saeed Gholamzadeh, Arya Hedjazi, Kamran Soltani, Jaber Gharehdaghi, Masoud Ghadipasha, Seyyed Mohammad Vahid Hosseini, Ahmad Zare
BACKGROUND: Medical errors such as retained foreign bodies (RFB) during surgery are not well studied. To define risk factors associated with this type of error, we performed retrospective study. METHODS: We reviewed medical records for unintentional foreign object remaining in the body during surgery such as gender, age, surgery ward, and incident reports referred to several forensic medicine administrations as well as adverse effects of retained foreign bodies and methods for detection of them over a 3-years period from January 2008 through May 2011...
March 2017: Annals of Medicine and Surgery
https://www.readbyqxmd.com/read/28215574/the-impact-of-pharmacy-services-on-opioid-prescribing-in-dental%C3%A2-practice
#8
Autumn Stewart, Kelsey J Zborovancik, Kara L Stiely
OBJECTIVES: To compare rates of dental opioid prescribing between periods of full and partial integration of pharmacy services and periods of no integration. METHODS: This observational study used a retrospective chart review of opioid prescriptions written by dental providers practicing in a free dental clinic for the medically underserved over a period of 74 months. Pharmacy services were fully integrated into the practice model for 48 of the 74 months under study...
February 15, 2017: Journal of the American Pharmacists Association: JAPhA
https://www.readbyqxmd.com/read/28213909/improving-prescribing-practices-a-pharmacist-led-educational-intervention-for-nurse-practitioner-students
#9
Jennifer A Sabatino, Maria C Pruchnicki, Alexa M Sevin, Elizabeth Barker, Christopher G Green, Kyle Porter
BACKGROUND AND PURPOSE: To assess impact of a pharmacist-led educational intervention on family nurse practitioner (FNP) students' prescribing skills, perception of preparedness to prescribe, and perception of pharmacist as collaborator. METHOD: Prospective pre-post assessment of a 14-week educational intervention in an FNP program in the spring semester of 2014. Students participated in an online module of weekly patient cases and prescriptions emphasizing legal requirements, prescription accuracy, and appropriate therapy...
February 18, 2017: Journal of the American Association of Nurse Practitioners
https://www.readbyqxmd.com/read/28213602/understanding-the-epidemiology-of-avoidable-significant-harm-in-primary-care-protocol-for-a-retrospective-cross-sectional-study
#10
Brian G Bell, Stephen Campbell, Andrew Carson-Stevens, Huw Prosser Evans, Alison Cooper, Christina Sheehan, Sarah Rodgers, Christine Johnson, Adrian Edwards, Sarah Armstrong, Rajnikant Mehta, Antony Chuter, Ailsa Donnelly, Darren M Ashcroft, Joanne Lymn, Pam Smith, Aziz Sheikh, Matthew Boyd, Anthony J Avery
INTRODUCTION: Most patient safety research has focused on specialist-care settings where there is an appreciation of the frequency and causes of medical errors, and the resulting burden of adverse events. There have, however, been few large-scale robust studies that have investigated the extent and severity of avoidable harm in primary care. To address this, we will conduct a 12-month retrospective cross-sectional study involving case note review of primary care patients. METHODS AND ANALYSIS: We will conduct electronic searches of general practice (GP) clinical computer systems to identify patients with avoidable significant harm...
February 17, 2017: BMJ Open
https://www.readbyqxmd.com/read/28207996/the-use-of-a-contextual-modal-and-psychological-classification-of-medication-errors-in-the-emergency-department-a-retrospective-descriptive-study
#11
C J Cabilan, J A Hughes, C Shannon
BACKGROUND: The causes of medication errors are unique in every clinical setting; hence error minimisation strategies are not always effective. For this reason, it is fundamental to understand the causes specific to the emergency department so that targeted strategies can be implemented. OBJECTIVES: To describe the contextual, modal, and psychological classification of medication errors in the emergency department to know the factors associated with the reported medication errors...
February 16, 2017: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/28205271/lean-six-sigma-methodologies-improve-clinical-laboratory-efficiency-and-reduce-turnaround-times
#12
Tamer C Inal, Ozlem Goruroglu Ozturk, Filiz Kibar, Salih Cetiner, Selcuk Matyar, Gulcin Daglioglu, Akgun Yaman
BACKGROUND: Organizing work flow is a major task of laboratory management. Recently, clinical laboratories have started to adopt methodologies such as Lean Six Sigma and some successful implementations have been reported. This study used Lean Six Sigma to simplify the laboratory work process and decrease the turnaround time by eliminating non-value-adding steps. METHODS: The five-stage Six Sigma system known as define, measure, analyze, improve, and control (DMAIC) is used to identify and solve problems...
February 15, 2017: Journal of Clinical Laboratory Analysis
https://www.readbyqxmd.com/read/28202233/practice-makes-perfect-a-systematic-review-of-the-expertise-development-of-pharmacist-and-nurse-independent-prescribers-in-the-united-kingdom
#13
REVIEW
Aseel S Abuzour, Penny J Lewis, Mary P Tully
BACKGROUND: Prescribing is a complex and error-prone task that demands expertise. McLellan et al.'s theory of expertise development model ("the model"), developed to assess medical literature on prescribing by medical students, proposes that in order to develop, individuals should deliberately engage their knowledge, skills and attitudes within a social context. Its applicability to independent prescribers (IP) is unknown. AIM: A systematic review was conducted to explore whether the model is applicable to non-medical independent prescribing and to assess the factors underpinning expertise development reported in the literature...
February 7, 2017: Research in Social & Administrative Pharmacy: RSAP
https://www.readbyqxmd.com/read/28199274/seven-step-pathway-for-preventing-errors-in-healthcare
#14
Rebin Zikhani
The Institute of Medicine's 1999 report To Err Is Human shed light on the grave consequences of medical errors and led to a substantial increase in awareness in the federal government and private sector regarding medical errors. In addition, the literature contains myriad solutions, strategies, and recommendations for dealing with this problem; however, because of their complexity and inflexibility, most cannot be implemented and are inapplicable on an individual level. This essay proposes a seven-step pathway for preventing errors-a flexible, feasible, and organized method that can be used by healthcare administrators and providers...
July 2016: Journal of Healthcare Management / American College of Healthcare Executives
https://www.readbyqxmd.com/read/28196503/validation-of-the-generic-medical-interview-satisfaction-scale-the-g-miss-questionnaire
#15
Axel Maurice-Szamburski, Pierre Michel, Anderson Loundou, Pascal Auquier
BACKGROUND: Patients have about seven medical consultations a year. Despite the importance of medical interviews in the healthcare process, there is no generic instrument to assess patients' experiences in general practices, medical specialties, and surgical specialties. The main objective was to validate a questionnaire assessing patients' experiences with medical consultations in various practices. METHOD: The G-MISS study was a prospective multi-center trial that enrolled patients from May to July 2016...
February 14, 2017: Health and Quality of Life Outcomes
https://www.readbyqxmd.com/read/28195561/automatic-and-hierarchical-segmentation-of-the-human-skeleton-in-ct-images
#16
Yabo Fu, Shi Liu, Hui Harold Li, Deshan Yang
Accurate segmentation of each bone in human skeleton is useful in many medical disciplines. Results of bone segmentation could facilitate bone disease diagnosis and post-treatment assessment, and support planning and image guidance for many treatment modalities including surgery and radiation therapy. As a medium level medical image processing task, accurate bone segmentation can facilitate automatic internal organ segmentation by providing stable structural reference for inter- or intra-patient registration and internal organ localization...
February 14, 2017: Physics in Medicine and Biology
https://www.readbyqxmd.com/read/28193376/radiology-research-in-quality-and-safety-current-trends-and-future-needs
#17
REVIEW
Matthew E Zygmont, Jason N Itri, Andrew B Rosenkrantz, Phuong-Anh T Duong, Lori Mankowski Gettle, Mishal Mendiratta-Lala, Elena P Scali, Ronald S Winokur, Linda Probyn, Justin W Kung, Eric Bakow, Nadja Kadom
Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care...
March 2017: Academic Radiology
https://www.readbyqxmd.com/read/28187810/management-of-infections-associated-with-neurocritical-care
#18
L Rivera-Lara, W Ziai, P Nyquist
The reported incidence of hospital-acquired infections (HAIs) in the neurointensive care unit (NICU) ranges from 20% to 30%. HAIs in US hospitals cost between $28 and $45 billion per year in direct medical costs. These infections are associated with increased length of hospital stay and increased morbidity and mortality. Infection risk is increased in NICU patients due to medication side-effects, catheter and line placement, neurosurgical procedures, and acquired immune suppression secondary to steroid/barbiturate use and brain injury itself...
2017: Handbook of Clinical Neurology
https://www.readbyqxmd.com/read/28187011/estimating-hospital-related-deaths-due-to-medical-error-a-perspective-from-patient-advocates
#19
Kevin T Kavanagh, Daniel M Saman, Rosie Bartel, Kim Westerman
The authors present a viewpoint regarding the quality of data used in estimating the number of preventable hospital deaths in the United States. Data derived from countries with a nationalized healthcare system with well-defined and near uniform implementation of standards may not be applicable to the fragmented noncentralized delivery system found in the United States. Although U.S. studies evaluating preventable mortality have based their projections on a small sample size, it is unlikely that this observation is due to chance, because other studies evaluating adverse events, a precursor to preventable mortality, have a much larger sample size and also report an unacceptably high number of events...
March 2017: Journal of Patient Safety
https://www.readbyqxmd.com/read/28186058/usability-validation-of-medical-devices-issues-in-identifying-potential-use-errors
#20
Jessica Schiro, Sylvia Pelayo, Thomas Weinhold, Marzia Del Zotto, Romaric Marcilly
In order to prevent use errors with their medical devices, manufacturers have to integrate a safety-oriented usability engineering process in their product development lifecycle. A critical step of this process is the identification of potential use-errors. Standards and guidelines recommend to triangulate several sources of information e.g. scientific literature, incident reports, manufacturer's files and user's feedbacks. This paper presents lessons learned from applying these recommendations during an international project...
2017: Studies in Health Technology and Informatics
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