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Medical error reporting

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https://www.readbyqxmd.com/read/28944923/-corrigendum-nonsense-mediated-mrna-decay-factor-upf2-exists-in-both-the-nucleoplasm-and-the-cytoplasm
#1
Takanori Tatsuno, Yuka Nakamura, Shaofu Ma, Naohisa Tomosugi, Yasuhito Ishigaki
Following the publication of this article, after having re-examined our manuscript, an error was noted in the Acknowledgments section regarding the funding of our study. The Acknowledgments section should have appeared as follows: "This work was supported by grants from the Kanazawa Medical University (nos. C2014-3, C2015-1 and S2014-15), a grant from the Strategic Research Project (no. H2012-16 [S1201022]) from Kanazawa Medical University, Ministry of Education, Culture, Sports, Science and Technology, Japan (KAKENHI no...
September 25, 2017: Molecular Medicine Reports
https://www.readbyqxmd.com/read/28943818/factors-associated-with-dispensing-dosage-delivery-devices
#2
Eva Wojewoda, Katherine J Chou
OBJECTIVES: A potential cause of medication errors in children is imprecise measurements, particularly using household spoons. There are no regulations requiring dispensing dose delivery devices (DDDs) with liquid prescription medications. Local, regional, and national pharmacy practice patterns are largely unknown. This study sought to determine how frequently devices are provided with prescription pediatric liquid medications with instructions for their use at pharmacies in Bronx, New York, and to examine which pharmacy and pharmacist characteristics are associated with reported practices...
July 2017: Journal of Pediatric Pharmacology and Therapeutics: JPPT: the Official Journal of PPAG
https://www.readbyqxmd.com/read/28934249/variability-in-objective-and-subjective-measures-affects-baseline-values-in-studies-of-patients-with-copd
#3
Wayne H Anderson, Jae Wook Ha, David J Couper, Wanda K O'Neal, R Graham Barr, Eugene R Bleecker, Elizabeth E Carretta, Christopher B Cooper, Claire M Doerschuk, M Bradley Drummond, MeiLan K Han, Nadia N Hansel, Victor Kim, Eric C Kleerup, Fernando J Martinez, Stephen I Rennard, Donald Tashkin, Prescott G Woodruff, Robert Paine, Jeffrey L Curtis, Richard E Kanner
RATIONALE: Understanding the reliability and repeatability of clinical measurements used in the diagnosis, treatment and monitoring of disease progression is of critical importance across all disciplines of clinical practice and in clinical trials to assess therapeutic efficacy and safety. OBJECTIVES: Our goal is to understand normal variability for assessing true changes in health status and to more accurately utilize this data to differentiate disease characteristics and outcomes...
2017: PloS One
https://www.readbyqxmd.com/read/28933275/a-case-of-inappropriate-self-medication-compounded-with-prescribing-vis-%C3%A3-vis-dispensing-errors-and-the-hazardous-consequence
#4
Sukalyan Saha Roy, Anupam Roy, Ranjita Santra Dhali, Chiranjib Bagchi, Gautam Banerjee, Santanu K Tripathi
INTRODUCTION Dispensing error, a type of medication error, is not infrequent but seldom reported. Self-medication behavior appears to be a commonplace. And when it is ignorant it may prove dangerous. We report here a case of acute vesico-bullous eruptions from methotrexate in a patient of psoriasis who indulged in self-medication and was wrongfully dispensed higher doses of methotrexate. CASE DESCRIPTION A 50-year-old gentleman presented to the dermatology OPD with erythematous, vesico-bullar lesions spread all over the body including both limbs and scalp, with oral mucosal involvement without any history of fever...
September 19, 2017: Current Drug Safety
https://www.readbyqxmd.com/read/28931497/use-of-simulation-based-on-an-electronic-health-records-environment-to-evaluate-the-structure-and-accuracy-of-notes-generated-by-medical-scribes-proof-of-concept-study
#5
Robert Pranaat, Vishnu Mohan, Megan O'Reilly, Maxwell Hirsh, Karess McGrath, Gretchen Scholl, Deborah Woodcock, Jeffrey A Gold
BACKGROUND: The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges...
September 20, 2017: JMIR Medical Informatics
https://www.readbyqxmd.com/read/28926146/nurses-clinical-reasoning-practices-that-support-safe-medication-administration-an-integrative-review-of-the-literature
#6
REVIEW
Emily Rohde, Elizabeth Domm
AIM AND OBJECTIVES: To review current literature about nurses' clinical reasoning practices that support safe medication administration. BACKGROUND: The literature about medication administration frequently focuses on avoiding medication errors. Nurses' clinical reasoning used during medication administration to maintain medication safety receives less attention in the literature. As health care professionals, nurses work closely with patients, assessing and intervening to promote mediation safety prior to, during and after medication administration...
September 19, 2017: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/28924562/assessment-of-analytical-performance-of-glucose-meter-in-pediatric-age-group-at-tertiary-care-referral-hospital
#7
Mohit Vijay Rojekar, Vandana Kumawat, Jayesh Panot, Surekha Khedkar, Arati Adhe-Rojekar
BACKGROUND: Glucometers are the excellent tools for self-monitoring of blood glucose (SMBG). They are important especially in the circumstances where continuous monitoring is mandatory and at decision making levels. Tight glycemic control protocols are important for preventing the ill effects of fluctuating glucose levels. This increases the use of glucometers in various healthcare settings. As technology advances, glucometers are getting better in terms of quality of results. But still some lacunae are there...
2017: Journal of Diabetes and Metabolic Disorders
https://www.readbyqxmd.com/read/28921446/can-a-novel-icu-data-display-positively-affect-patient-outcomes-and-save-lives
#8
Natalia Olchanski, Mikhail A Dziadzko, Ing C Tiong, Craig E Daniels, Steve G Peters, John C O'Horo, Michelle N Gong
The aim of this study was to quantify the impact of ProCCESs AWARE, Ambient Clinical Analytics, Rochester, MN, a novel acute care electronic medical record interface, on a range of care process and patient health outcome metrics in intensive care units (ICUs). ProCCESs AWARE is a novel acute care EMR interface that contains built-in tools for error prevention, practice surveillance, decision support and reporting. We compared outcomes before and after AWARE implementation using a prospective cohort and a historical control...
September 18, 2017: Journal of Medical Systems
https://www.readbyqxmd.com/read/28916249/diagnostic-errors-impact-of-an-educational-intervention-on-pediatric-primary-care
#9
Julianne Nemes Walsh, Margaret Knight, A James Lee
INTRODUCTION: The purpose of our study was to determine the impact of an educational program on a provider's knowledge related to diagnostic errors and diagnostic reasoning strategies. METHODS: A quasi-experimental interventional study with a multimedia approach, case study discussion, and trigger-generated medical record review at two time points was conducted. Measurement tools included a test developed by the National Patient Safety Foundation, Reducing Diagnostic Errors: Strategies for Solutions Quiz, additional diagnostic reasoning questions, and a trigger-generated process to analyze medical records...
September 12, 2017: Journal of Pediatric Health Care
https://www.readbyqxmd.com/read/28915106/making-sense-of-a-haemolysis-monitoring-and-reporting-system-a-nationwide-longitudinal-multimethod-study-of-68-australian-laboratory-participant-organisations
#10
Ling Li, Elia Vecellio, Stephanie Gay, Rebecca Lake, Mark Mackay, Leslie Burnett, Douglas Chesher, Stephen Braye, Tony Badrick, Johanna I Westbrook, Andrew Georgiou
BACKGROUND: The key incident monitoring and management systems (KIMMS) quality assurance program monitors incidents in the pre- and postanalytical phases of testing in medical laboratories. Haemolysed specimens have been found to be the most frequent preanalytical error and have major implications for patient care. The aims of this study were to assess the suitability of KIMMS for quality reporting of haemolysis and to devise a meaningful method for reporting and monitoring haemolysis...
September 15, 2017: Clinical Chemistry and Laboratory Medicine: CCLM
https://www.readbyqxmd.com/read/28910397/a-three-dimensional-strain-measurement-method-in-elastic-transparent-materials-using-tomographic-particle-image-velocimetry
#11
Azuma Takahashi, Sara Suzuki, Yusuke Aoyama, Mitsuo Umezu, Kiyotaka Iwasaki
BACKGROUND: The mechanical interaction between blood vessels and medical devices can induce strains in these vessels. Measuring and understanding these strains is necessary to identify the causes of vascular complications. This study develops a method to measure the three-dimensional (3D) distribution of strain using tomographic particle image velocimetry (Tomo-PIV) and compares the measurement accuracy with the gauge strain in tensile tests. METHODS AND FINDINGS: The test system for measuring 3D strain distribution consists of two cameras, a laser, a universal testing machine, an acrylic chamber with a glycerol water solution for adjusting the refractive index with the silicone, and dumbbell-shaped specimens mixed with fluorescent tracer particles...
2017: PloS One
https://www.readbyqxmd.com/read/28905302/non-health-care-facility-medication-errors-associated-with-hormones-and-hormone-antagonists-in-the-united-states
#12
Pranav Magal, Henry A Spiller, Marcel J Casavant, Thitphalak Chounthirath, Nichole L Hodges, Gary A Smith
INTRODUCTION: Hormones and hormone antagonists are frequently associated with medication errors and may result in important adverse outcomes. The purpose of this study is to investigate non-health care facility (non-HCF) medication errors associated with hormones and hormone antagonists in the United States (US). METHODS: A retrospective analysis of National Poison Data System data was conducted to identify characteristics and trends of unintentional non-HCF therapeutic errors involving hormones and hormone antagonists among individuals of all ages from 2000 to 2012...
September 13, 2017: Journal of Medical Toxicology: Official Journal of the American College of Medical Toxicology
https://www.readbyqxmd.com/read/28895231/software-related-recalls-of-health-information-technology-and-other-medical-devices-implications-for-fda-regulation-of-digital-health
#13
Jay G Ronquillo, Diana M Zuckerman
Policy Points: Medical software has become an increasingly critical component of health care, yet the regulation of these devices is inconsistent and controversial. No studies of medical devices and software assess the impact on patient safety of the FDA's current regulatory safeguards and new legislative changes to those standards. Our analysis quantifies the impact of software problems in regulated medical devices and indicates that current regulations are necessary but not sufficient for ensuring patient safety by identifying and eliminating dangerous defects in software currently on the market...
September 2017: Milbank Quarterly
https://www.readbyqxmd.com/read/28890920/how-did-i-miss-that-developing-mixed-hybrid-visual-search-as-a-model-system-for-incidental-finding-errors-in-radiology
#14
Jeremy M Wolfe, Abla Alaoui Soce, Hayden M Schill
In a real world search, it can be important to keep 'an eye out' for items of interest that are not the primary subject of the search. For instance, you might look for the exit sign on the freeway, but you should also respond to the armadillo crossing the road. In medicine, these items are known as "incidental findings," findings of possible clinical significance that were not the main object of search. These errors (e.g., missing a broken rib while looking for pneumonia) have medical consequences for the patient and potential legal consequences for the physician...
2017: Cognitive Research: Principles and Implications
https://www.readbyqxmd.com/read/28887292/protocol-for-usability-testing-and-validation-of-the-iso-draft-international-standard-19223-for-lung-ventilators
#15
Dev Minotra, Steven L Dain, Catherine M Burns
BACKGROUND: Clinicians, such as respiratory therapists and physicians, are often required to set up pieces of medical equipment that use inconsistent terminology. Current lung ventilator terminology that is used by different manufacturers contributes to the risk of usage errors, and in turn the risk of ventilator-associated lung injuries and other conditions. Human factors and communication issues are often associated with ventilator-related sentinel events, and inconsistent ventilator terminology compounds these issues...
September 8, 2017: JMIR Research Protocols
https://www.readbyqxmd.com/read/28883675/developing-the-medication-reminder-mobile-application-seeb
#16
Sakineh Saghaeiannejad-Isfahani, Asghar Ehteshami, Ebtesam Savari, Ali Samimi
INTRODUCTION: Today, the structure of comprehensive health care emphasizes self-care more than therapy. Medication therapy is a strong instrument for therapy received through the health setting, especially in medication area. Error in medication administration has produced different problems and they cost billions of dollars every year. Regarding mobile phone extensions, we developed a local medication reminder mobile application called "Seeb" as a suitable solution for decreasing medication errors for Iranians...
June 2017: Acta Informatica Medica: AIM
https://www.readbyqxmd.com/read/28883173/data-collection-of-medication-impact-of-autocompletion-in-ecrfs-on-efficiency-and-data-quality
#17
Tolga P Naziyok, Corinna Feeken, Atinkut A Zeleke, Michael Dörks, Rainer Röhrig
OBJECTIVE: Openclinica Input Completion (OIC) was developed to increase the efficiency to enter drugs in eCRF in OpenClinica<sup>®</sup>. The aim of the study was to evaluate the impact on efficiency and data quality as well as usability. METHODS: 20 participants were asked to input 15 drugs with the new tool and by hand. RESULTS: The mean input time got decreased from 16:12m to 3:59m. 31 of 300 (10%) of manual entered medication data sets had one or more errors versus 10 of 300 (3,3%) data sets entered with OIC...
2017: Studies in Health Technology and Informatics
https://www.readbyqxmd.com/read/28878928/evaluation-of-a-guided-continuous-quality-improvement-program-in-community-pharmacies
#18
Chanadda Chinthammit, Michael T Rupp, Edward P Armstrong, Tara Modisett, Rebecca P Snead, Terri L Warholak
BACKGROUND: The importance of creating and sustaining a strong culture of patient safety has been recognized as a critical component of safe medication use. This study aims to assess changes in attitudes toward patient safety culture and frequency of quality-related event (QRE) reporting after guided implementation of a continuous quality improvement (CQI) program in a panel of community pharmacies in the United States (U.S.). METHODS: Twenty-one community pharmacies volunteered to participate in the project and were randomly assigned to intervention or control groups...
2017: Journal of Pharmaceutical Policy and Practice
https://www.readbyqxmd.com/read/28874948/impact-of-internally-developed-electronic-prescription-on-prescribing-errors-at-discharge-from-the-emergency-department
#19
Eveline Hitti, Hani Tamim, Rinad Bakhti, Dina Zebian, Afif Mufarrij
INTRODUCTION: Medication errors are common, with studies reporting at least one error per patient encounter. At hospital discharge, medication errors vary from 15%-38%. However, studies assessing the effect of an internally developed electronic (E)-prescription system at discharge from an emergency department (ED) are comparatively minimal. Additionally, commercially available electronic solutions are cost-prohibitive in many resource-limited settings. We assessed the impact of introducing an internally developed, low-cost E-prescription system, with a list of commonly prescribed medications, on prescription error rates at discharge from the ED, compared to handwritten prescriptions...
August 2017: Western Journal of Emergency Medicine
https://www.readbyqxmd.com/read/28872354/video-and-clinical-screening-of-national-rugby-league-players-suspected-of-sustaining-concussion
#20
Andrew J Gardner, Magdalena Wojtowicz, Douglas P Terry, Christopher R Levi, Ross Zafonte DO, Grant L Iverson
PRIMARY OBJECTIVE: This study reviewed the available sideline Sport Concussion Assessment Tool-Third Edition (SCAT3) performance of players who were removed from play using the 'concussion interchange rule' (CIR), the available video footage of these incidences, and associated return to play and concussion diagnosis decisions. RESEARCH DESIGN: Descriptive, observational case series. METHODS AND PROCEDURES: Data were collected from all NRL players who used the CIR during the 2014 season...
September 5, 2017: Brain Injury: [BI]
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