Best practice error prevention

Introduction Blood tests are essential for detecting and treating hospitalized individuals with diseases. Laboratory blood tests provide doctors with critical information required to treat their patient's illnesses. The most common sources of error in clinical laboratories are pre-analytical errors. Although quality control measures can remediate analytical errors, there is a requirement for stringent quality checks in the pre-analytical sector as these activities are performed outside of the laboratory...

BACKGROUND: Medication errors are common in residential aged care facilities (RACFs) due to several factors. Effective medication management is essential to prevent medication errors among older people particularly due to the complexity of co-morbidities they can experience. OBJECTIVES: This study aimed to examine and quantify the contributing factors of medication errors from nurses' perspectives and the prevention strategies to reduce medication errors among older adults living in RACFs...

Measure something, and it gets better-this is what is called as the Hawthorne effect (also known as the observer effect). The Hawthorne factory experiments in 1920s were remarkable industrial data collection and analysis exercises that lead to Edwards Deming's quality revolution. The Harvard Medical Practice Study (1991), Leape's "Error in Medicine" (1994), and the Bristol pediatric cardiac report (2001) are among many documents that have revealed the huge gap between best practices and actual medical practice...

Best international practices for road safetyRoad transportation is not only a vital component of how cities grow and how society functions, but it is also a significant factor that can affect the frequency of serious accidents and traumas. Human failure is not omitted, addressing it at the system level, involving the prevention of fatal and severe accidents, reducing mortality, and the cost itself. With the aim of outlining the best ways to improve road traffic, and prevent road trauma we have observed the experience of different countries in this regard...

PURPOSE: The aim of this quality improvement (QI) project was to explore prevention strategies to reduce tubing and device misconnections that cause patient harm and death. Practicing evidence-based techniques can improve rates of nursing-sensitive indicators, such as central line-associated bloodstream infections, and increase patient safety. METHODS: Our nursing quality management team reviewed internal quality data and found 11 reported misconnections. A literature review was performed to identify recommended prevention strategies that have been used to improve patient outcomes...

Errors in clinical decision-making are disturbingly common. Recent studies have found that 10 to 15% of all clinical decisions regarding diagnoses and treatment are inaccurate. Here, we experimentally study the ability of structured information-sharing networks among clinicians to improve clinicians' diagnostic accuracy and treatment decisions. We use a pool of 2,941 practicing clinicians recruited from around the United States to conduct 84 independent group-level trials, ranging across seven different clinical vignettes for topics known to exhibit high rates of diagnostic or treatment error (e...

INTRODUCTION: An important part of anesthesia management is opening and maintaining the patient's airway. Failure to establish and maintain a safe airway for patients during anesthesia is a life-threatening condition. Despite advances in science and technology, difficult airway management is far from ideal. Providing a simulated environment for critical situations seems to be the best way to better educate and prevent medical errors. This study aimed to compare the effect of the FIRST2ACT (Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trend) model on knowledge and practical skills of difficult airway management and respiratory accidents between the intervention and control groups...

BACKGROUND: Schistosomiasis is of great public health concern with a wide distribution and multiple determinants. Due to the advances in schistosomiasis elimination and the need for precision prevention and control, identifying determinants at a fine scale is urgent and necessary, especially for resource deployment in practice. Our study aimed to identify the determinants for the seropositive rate of schistosomiasis at the village level and to explore their spatial variations in local space...

Optimizing treatments requires the prevention of diagnostic errors. The use of shortcuts, cognitive biases, may lead to errors of judgement that can impair clinical reasoning and distort decision-making. Objective, quantifiable and comparable assessment is a safeguard against this, and for instance force quantification is used for this purpose. We will present here the use of hand-held dynamometers with recommendations for best practice as well as simple but essential tools for interpreting the results. Indeed, the use of these easy-to-use dynamometers requires rigour to ensure the quality of measurements and data analysis by/for the clinician...

Clinical decision support (CDS) can prevent medical errors and improve patient outcomes. Electronic health record (EHR)-based CDS, designed to facilitate prescription drug monitoring program (PDMP) review, has reduced inappropriate opioid prescribing. However, the pooled effectiveness of CDS has exhibited substantial heterogeneity and current literature does not adequately detail why certain CDS are more successful than others. Clinicians regularly override CDS, limiting its impact. No studies recommend how to help nonadopters recognize and recover from CDS misuse...

Accurate measurement of sexual violence (SV) victimization is important for informing research, policy, and service provision. Measures such as the Sexual Experiences Survey (SES) that use behaviorally specific language and a specified reference period (e.g., since age 14, over the past 12 months) are considered best practice and have substantially improved SV estimates given that so few incidents are reported to police. However, to date, we know little about whether estimates are affected by respondents' reporting of incidents that occurred outside of the specified reference period (i...

The climate change crisis comprises a central threat to public health. The health outcomes of this crisis are well-known, but lesser known to medical professionals is the role that health care delivery plays in worsening this crisis. The United States health care system is responsible for producing 10% of total greenhouse gases. The adverse health outcomes caused by overall health care system emissions in the U.S. is estimated at 470,000 disability-adjusted life years lost, which is commensurate with the 44,000-98,000 people who die in hospitals each year in the U...

The novel coronavirus (COVID-19), also known as SARS-CoV-2, is a highly contagious respiratory disease that first emerged in Wuhan, China in 2019 and has since become a global pandemic. The virus is spread through respiratory droplets produced when an infected person coughs or sneezes, and it can lead to a range of symptoms, from mild to severe. Some people may not have any symptoms at all and can still spread the virus to others. The best way to prevent the spread of COVID-19 is to practice good hygiene. It is also important to follow the guidelines set by local health authorities, such as physical distancing and quarantine measures...

BACKGROUND: The Ministry of Health and Family Welfare has introduced the "National Patient Safety Implementation Framework" to ensure the patient safety at different levels of healthcare delivery system. However, there is limited effort made in evaluating the implementation status of this framework. Hence, we have performed the process evaluation of National Patient Safety Implementation Framework across the public healthcare facilities in Tamil Nadu. METHODS: This was a facility-level survey conducted by research assistants who visited 18 public health facilities across 6 districts of Tamil Nadu, India, for the purpose of documenting the presence of structural support systems and strategies to promote patient safety...

AIM: An integrative review of the literature was conducted to explore perceptions of distractors and interruptions during nurse-to-nurse handoff. BACKGROUND: Handoff distractors and interruptions are recognized as barriers to effective nurse handoff and may lead to preventable and costly medical errors. However, little is known about the perception of these barriers to nurses and strategies to mitigate distractors and interruptions during nurse-to-nurse handoff...

BACKGROUND: Severe hyperammonaemia is associated with significant morbidity and mortality. Rapid analysis and reporting of ammonia results is essential to prevent patient harm. The aim was to investigate the laboratory sample acceptance criteria, ammonia analysis and the reporting of ammonia results. METHODS: A questionnaire was distributed to clinical biochemistry laboratories in the United Kingdom. The results were collated and compared to updated best practice guidelines on hyperammonaemia issued by the Metabolic Biochemistry Network (MetBio...

BACKGROUND: Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence. OBJECTIVES: The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit...

Aflatoxin contamination in corn is a significant issue, posing substantial health threats to humans and animals. Aflatoxin testing protects consumer health, ensures the safe global trade of corn, and verifies compliance with legislation; however, effective sampling procedures are essential to ensure reliable results. While many sampling procedures exist, there is no evidence to indicate which is the best approach to ensure accurate detection. Using scientific and gray literature sources, this review analyzed sampling procedures to determine an optimum approach to guide the development of standard practices...

Canadian regulations require food business operators (FBOs) to implement preventive controls to manage allergens and ensure their accurate declaration. However, the use of precautionary allergen labelling (PAL) is voluntary and competent authorities provide limited guidance on its use. The objective of this study was to present an overview of Canadian FBOs' current allergen management practices, including the mechanisms used to evaluate the need for PAL in finished products, and to investigate potential areas for improvement...

Background: Healthcare organizations are often committed to preventing suicide among their patients, but they can struggle to adequately train providers and implement strategies grounded in evidence-based suicide prevention practices. Virtual patient simulations (VPS) offer the opportunity for providers at healthcare organizations and educational institutions to learn suicide prevention strategies using a realistic and risk-free environment. The purpose of this study was to gather feedback from leaders in the healthcare field regarding the feasibility and acceptability of VPS for their organizations...