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Medical error reporting

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https://www.readbyqxmd.com/read/28808959/deaths-from-medicines-a-systematic-analysis-of-coroners-reports-to-prevent-future-deaths
#1
Robin E Ferner, Craig Easton, Anthony R Cox
INTRODUCTION: Since legislation in 2009, coroners in England and Wales must make reports in cases where they believe it is possible to prevent future deaths. We categorised the reports and examined whether they could reveal preventable medication errors or novel adverse drug reactions. METHODS: We examined 500 coroners' reports by pre-defined criteria to identify those in which medicines played a part, and to collect information on coroners' concerns. RESULTS: We identified 99 reports (100 deaths) in which medicines or a part of the medication process or both were mentioned...
August 14, 2017: Drug Safety: An International Journal of Medical Toxicology and Drug Experience
https://www.readbyqxmd.com/read/28800287/measuring-and-establishing-the-accuracy-and-reproducibility-of-3d-printed-medical-models
#2
Elizabeth George, Peter Liacouras, Frank J Rybicki, Dimitrios Mitsouras
Despite the rapid growth of three-dimensional (3D) printing applications in medicine, the accuracy and reproducibility of 3D printed medical models have not been thoroughly investigated. Although current technologies enable 3D models to be created with accuracy within the limits of clinical imaging spatial resolutions, this is not always achieved in practice. Inaccuracies are due to errors that occur during the imaging, segmentation, postprocessing, and 3D printing steps. Radiologists' understanding of the factors that influence 3D printed model accuracy and the metrics used to measure this accuracy is key in directing appropriate practices and establishing reference standards and validation procedures...
August 11, 2017: Radiographics: a Review Publication of the Radiological Society of North America, Inc
https://www.readbyqxmd.com/read/28795338/evaluation-of-patient-and-family-engagement-strategies-to-improve-medication-safety
#3
REVIEW
Julia M Kim, Catalina Suarez-Cuervo, Zackary Berger, Joy Lee, Jessica Gayleard, Carol Rosenberg, Natalia Nagy, Kristina Weeks, Sydney Dy
BACKGROUND: Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety. METHODS: We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles were additionally reviewed by two senior investigators for selection. One investigator abstracted data and two investigators reviewed the data for accuracy...
August 9, 2017: Patient
https://www.readbyqxmd.com/read/28782193/resident-responses-to-after-hours-otolaryngology-patient-phone-calls-an-overlooked-aspect-of-residency-training
#4
Ashton E Lehmann, Elliott D Kozin, Rosh K V Sethi, Kevin Wong, Brian M Lin, Stacey T Gray, Michael J Cunningham
OBJECTIVES/HYPOTHESIS: Otolaryngology residents are often responsible for triaging after-hours patient calls. However, residents receive little training on this topic. Data are limited on the clinical content, reporting, and management of otolaryngology patient calls. This study aimed to characterize the patient concerns residents handle by phone and their subsequent management and reporting. STUDY DESIGN: Retrospective review. METHODS: Five hundred consecutive after-hours patient calls in a tertiary pediatric hospital were reviewed...
August 7, 2017: Laryngoscope
https://www.readbyqxmd.com/read/28780844/-analysis-of-the-clinical-characteristics-and-efficacy-of-20-cases-of-extranodal-rosai-dorfman-disease-in-head-and-neck
#5
L Cui, C L Yue
Objective: To analyze the clinical characteristics and efficacy of extranodal Rosai-Dorfman disease in head and neck. Methods: Clinical and pathological features and follow-up of patients who were diagnosed as RDD at Beijing Tongren Hospital of Capital Medical University between May 2008 and November 2016 were analyzed retrospectively. Results: There were a total of 20 extranodal RDD patients in head and neck including 14 females and 6 males, aged from 27 to 86 years (mean 52.5 years). Nose (14 cases) and throat (5 cases) were most commonly involved organs and 5 patients had 2 or more organs involved...
August 1, 2017: Zhonghua Yi Xue za Zhi [Chinese medical journal]
https://www.readbyqxmd.com/read/28776442/structure-and-activities-of-pharmacy-and-therapeutics-committees-among-public-hospitals-in-south-africa-findings-and-implications
#6
Moliehi Matlala, Andries Gs Gous, Brian Godman, Johanna C Meyer
The WHO identified Pharmacy and Therapeutics Committees (PTCs) as a pivotal model to promote rational medicine use in hospitals. This matches a key South African (SA) government objective to establish PTCs in all hospitals to ensure rational, efficient and cost-effective use of medicines. However, documentation on the functionality of PTCs in public hospitals in SA is limited. Areas covered: This study aimed to address this. A 3-phased mixed methods approach involving questionnaires, observations of PTC meetings and semi-structured interviews was used...
August 16, 2017: Expert Review of Clinical Pharmacology
https://www.readbyqxmd.com/read/28774169/medication-errors-among-nurses-in-teaching-hospitals-in-the-west-of-iran-what-we-need-to-know-about-prevalence-types-and-barriers-to-reporting
#7
Afshin Fathi, Mohammad Hajizadeh, Khalil Moradi, Hamed Zandian, Maryam Dezhkameh, Shima Kazemzadeh, Satar Rezaei
OBJECTIVES: This study aimed to examine the prevalence and types of medication errors (MEs), as well as barriers to reporting MEs, among nurses working in 7 teaching hospitals affiliated with Kermanshah University of Medical Sciences in 2016. METHODS: A convenience sampling method was used to select the study participants (n=500 nurses). A self-constructed questionnaire was employed to collect information on participants' socio-demographic characteristics (10 items), their perceptions about the main causes of MEs (31 items), and barriers to reporting MEs to nurse managers (11 items)...
2017: Epidemiology and Health
https://www.readbyqxmd.com/read/28771653/impact-of-polypharmacy-on-seniors-self-perceived-health-status
#8
Rafia Rasu, Walter Agbor-Bawa, Nahid Rianon
OBJECTIVES: Polypharmacy is common among older patients and is linked to increased risk of adverse health outcomes. This study aimed to explore the association of polypharmacy and self-perceived health status (SPHS) among geriatric patients. METHODS: This cross-sectional analysis of longitudinal observational research used national survey data from 2005-2008. Multivariate logistic regressions examined the likelihood of having a good/poor SPHS and polypharmacy. Medical Expenditure Panel Survey data provided by Agency for Healthcare Research and Quality were used in this study...
August 2017: Southern Medical Journal
https://www.readbyqxmd.com/read/28768684/parent-provider-miscommunications-in-hospitalized-children
#9
Alisa Khan, Stephannie L Furtak, Patrice Melvin, Jayne E Rogers, Mark A Schuster, Christopher P Landrigan
BACKGROUND: Miscommunications lead to medical errors and suboptimal hospital experience. Parent-provider miscommunications are understudied. OBJECTIVES: (1) Examine characteristics of parent-provider miscommunications about hospitalized children, (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience, and (3) compare parent and attending physician reports of parent-provider miscommunications. METHODS: Prospective cohort study of 471 parents of 0- to 17-year-old medical inpatients in a pediatric hospital between May 1, 2013 and October 1, 2014...
August 2, 2017: Hospital Pediatrics
https://www.readbyqxmd.com/read/28764780/improving-patient-safety-culture-in-saudi-arabia-2012-2015-trending-improvement-and-benchmarking
#10
Khalid Alswat, Rawia Ahmad Mustafa Abdalla, Maher Abdelraheim Titi, Maram Bakash, Faiza Mehmood, Beena Zubairi, Diana Jamal, Fadi El-Jardali
BACKGROUND: Measuring patient safety culture can provide insight into areas for improvement and help monitor changes over time. This study details the findings of a re-assessment of patient safety culture in a multi-site Medical City in Riyadh, Kingdom of Saudi Arabia (KSA). Results were compared to an earlier assessment conducted in 2012 and benchmarked with regional and international studies. Such assessments can provide hospital leadership with insight on how their hospital is performing on patient safety culture composites as a result of quality improvement plans...
August 2, 2017: BMC Health Services Research
https://www.readbyqxmd.com/read/28760164/acute-chemical-incidents-with-injured-first-responders-2002-2012
#11
Natalia Melnikova, Jennifer Wu, Alice Yang, Maureen Orr
Introduction First responders, including firefighters, police officers, emergency medical services, and company emergency response team members, have dangerous jobs that can bring them in contact with hazardous chemicals among other dangers. Limited information is available on responder injuries that occur during hazardous chemical incidents. METHODS: We analyzed 2002-2012 data on acute chemical incidents with injured responders from 2 Agency for Toxic Substances and Disease Registry chemical incident surveillance programs...
August 1, 2017: Disaster Medicine and Public Health Preparedness
https://www.readbyqxmd.com/read/28757690/prognostic-preoperative-factors-for-successful-outcome-of-surgery-in-horizontal-strabismus
#12
Namita Kumari, Abadan Khan Amitava, Mohammad Ashraf, Shivani Grover, Ashiya Khan, Prabha Sonwani
CONTEXT: Surgery for horizontal strabismus reportedly has a success rate of 60%-80%. However, which preoperative factors are predictive of this success is not clear. AIMS: To identify prognostic factors those are predictive of successful outcome in horizontal strabismus surgery. SETTINGS AND DESIGN: Observational analytical study using multiple logistic regression (MLR). SUBJECTS AND METHODS: We assessed the medical records of patients who had undergone first-time horizontal muscle strabismus surgery between 2002 and 2013, where complete follow-up data were available for ≥6 weeks, and also, we collected data prospectively on patients operated between January 2014 and September 2015...
May 2017: Oman Journal of Ophthalmology
https://www.readbyqxmd.com/read/28756146/two-year-experience-implementing-a-curriculum-to-improve-residents-patient-centered-communication-skills
#13
Amber W Trickey, Anna B Newcomb, Melissa Porrey, Franco Piscitani, Jeffrey Wright, Paula Graling, Jonathan Dort
OBJECTIVES: Surgery milestones from The Accreditation Council for Graduate Medical Education have encouraged a focus on training and assessment of residents' nontechnical skills, including communication. We describe our 2-year experience implementing a simulation-based curriculum, results of annual communication performance assessments, and resident evaluations. DESIGN: Eight quarterly modules were conducted on various communication topics. Former patient volunteers served as simulation participants (SP) who completed annual assessments using the Communication Assessment Tool (CAT)...
July 26, 2017: Journal of Surgical Education
https://www.readbyqxmd.com/read/28753130/pilot-study-of-quality-of-care-training-and-knowledge-in-sub-saharan-african-medical-schools
#14
Diana Bowser, Yasmin Abbas, Temitope Odunleye, Edward Broughton, Thomas Bossert
Objectives: To identify the level of knowledge and competencies related to quality of care during medical education in sub-Saharan African medical schools. Methods: A cross-sectional study design was utilized to examine the capacity of medical schools in sub-Saharan African (SSA) countries to teach about the concepts of quality of care and the inclusion of these concepts in their curriculum. A purposeful convenience sampling technique was used to select participants from 25 medical schools in 5 sub-Saharan African countries...
July 24, 2017: International Journal of Medical Education
https://www.readbyqxmd.com/read/28752894/headache-in-idiopathic-intracranial-hypertension-findings-from-the-idiopathic-intracranial-hypertension-treatment-trial
#15
Deborah I Friedman, Peter A Quiros, Prem S Subramanian, Luis J Mejico, Shan Gao, Michael McDermott, Michael Wall
OBJECTIVE: To characterize the phenotype, headache-related disability, medical co-morbidities, use of symptomatic headache medications, and headache response to study interventions in the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT). METHODS: Patients with untreated IIH and mild vision loss enrolled in the IIHTT and randomized to acetazolamide (ACZ) and weight loss or placebo (PLB) and weight loss had prospective assessment of headache disability using the Headache Impact Test-6 (HIT-6) questionnaire...
July 28, 2017: Headache
https://www.readbyqxmd.com/read/28752179/-clinical-autopsies-in-switzerland-a-status-report
#16
REVIEW
A-K Rodewald, P Bode, G Cathomas, H Moch
BACKGROUND: The number of autopsies has been steadily declining worldwide over the past decades. The reasons for this are diverse. Legislation regarding opposition and consent rules does not appear to have had a significant impact on the autopsy rates. Above all, structural causes and the attitude of the medical profession are the reasons for this decline. The main argument for a high autopsy rate is the identification of diagnostic errors; however, diagnostic discrepancies are relatively independent of the rate of autopsies performed...
July 27, 2017: Der Pathologe
https://www.readbyqxmd.com/read/28751484/medication-incidents-in-primary-care-medicine-a-prospective-study-in-the-swiss-sentinel-surveillance-network-sentinella
#17
Markus Gnädinger, Dieter Conen, Lilli Herzig, Milo A Puhan, Alfred Staehelin, Marco Zoller, Alessandro Ceschi
OBJECTIVES: To describe the type, frequency, seasonal and regional distribution of medication incidents in primary care in Switzerland and to elucidate possible risk factors for medication incidents. DESIGN: Prospective surveillance study. SETTING: Swiss primary healthcare, Swiss Sentinel Surveillance Network. PARTICIPANTS: Patients with drug treatment who experienced any erroneous event related to the medication process and interfering with normal treatment course, as judged by their physician...
July 26, 2017: BMJ Open
https://www.readbyqxmd.com/read/28749896/elimination-of-anterior-corneal-steepening-with-descemet-membrane-endothelial-keratoplasty-in-a-patient-with-fuchs-dystrophy-and-keratoconus-implications-for-iol-calculation
#18
Reena Gupta, Ruta Kinderyte, Deborah S Jacobs, Ula V Jurkunas
PURPOSE: To report a case of coexistent Fuchs endothelial corneal dystrophy (FECD) and keratoconus (KCN) in which there was normalization of corneal topography after Descemet membrane endothelial keratoplasty (DMEK). METHODS: Retrospective medical record review. RESULTS: Preoperative findings revealed a best-corrected visual acuity of 20/40 with -1.00 - 2.50 × 147, topographic maximum keratometry of 50.8 D with inferior steeping, and confluent guttae in the left eye...
July 26, 2017: Cornea
https://www.readbyqxmd.com/read/28748359/analysis-of-medication-errors-at-a-large-tertiary-care-hospital-in-saudi-arabia-a-retrospective-analysis
#19
Sheraz Ali, Nourah Ibrahim Aboheimed, Ibrahim Abdulaziz Al-Zaagi, Dalal Salem Al-Dossari
Background Medication errors (MEs) are common in health care settings and pose a threat for the hospitalized population. Therefore, aspects of MEs were explored in a tertiary setting serving a diverse population. Objective To examine the occurrence, severity and reporting of MEs in hospitalized patients. Methods This retrospective analysis included 10,683 ME report forms that were received by the Medication Safety Unit of King Saud Medical City (KSMC) in 2015. ME outcomes were determined according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for categorizing MEs algorithm...
July 26, 2017: International Journal of Clinical Pharmacy
https://www.readbyqxmd.com/read/28747134/reporting-medical-device-safety-incidents-to-regulatory-authorities-an-analysis-and-classification-of-technology-induced-errors
#20
Sari Palojoki, Kaija Saranto, Lasse Lehtonen
The European Union Medical Device Directive 2007/47/EC1 defines software with a medical purpose as a medical device. The implementation of health information technology suffers from patient safety problems that require effective post-market surveillance. The purpose of this study was to review, classify and discuss the incident data submitted to a nationwide database of the Finnish National Competent Authority with other forms of data. We analysed incident reports submitted to the authority database by users of electronic health records from 2010 to 2015...
July 1, 2017: Health Informatics Journal
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