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Medication errors

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https://www.readbyqxmd.com/read/28102918/medication-administration-errors-and-related-deviations-from-safe-practice-an-observational-study
#1
Alwiena J Blignaut, Siedine K Coetzee, Hester C Klopper, Suria M Ellis
AIMS AND OBJECTIVES: To determine the incidence of medication administration errors, medication administration related deviations from safe practice as well as factors associated with these errors in medical and surgical units of public hospitals in the Gauteng Province of South Africa. BACKGROUND: Several studies have been published on the incidence of medication administration errors, but only a few have studied the incidence of medication administration related deviations from safe practice...
January 19, 2017: Journal of Clinical Nursing
https://www.readbyqxmd.com/read/28101668/results-of-a%C3%A2-population-based-assessment-we-need-better-communication-and-more-profound-patient-involvement
#2
Gerald Sendlhofer, Gudrun Pregartner, Karina Leitgeb, Magdalena Hoffmann, Andrea Berghold, Christian Smolle, Gernot Brunner, Lars Peter Kamolz
BACKGROUND: In Austria several regulations were published in order to support initiatives to increase patient safety. Since then, many patient safety projects were implemented in Austrian hospitals; therefore, it was the aim of the current survey to examine the perceptions of Austrian citizens with respect to topics relevant to patient safety. METHODS: Between 8 and 22 October 2015 a qualitative cross-sectional telephone interview study was performed. A sample of citizens above 14 years of age was randomly drawn...
January 18, 2017: Wiener Klinische Wochenschrift
https://www.readbyqxmd.com/read/28099792/implementing-an-error-disclosure-coaching-model-a-multicenter-case-study
#3
Andrew A White, Douglas M Brock, Patricia I McCotter, Sarah E Shannon, Thomas H Gallagher
National guidelines call for health care organizations to provide around-the-clock coaching for medical error disclosure. However, frontline clinicians may not always seek risk managers for coaching. As part of a demonstration project designed to improve patient safety and reduce malpractice liability, we trained multidisciplinary disclosure coaches at 8 health care organizations in Washington State. The training was highly rated by participants, although not all emerged confident in their coaching skill. This multisite intervention can serve as a model for other organizations looking to enhance existing disclosure capabilities...
January 2017: Journal of Healthcare Risk Management: the Journal of the American Society for Healthcare Risk Management
https://www.readbyqxmd.com/read/28099789/ehr-related-medication-errors-in-two-icus
#4
Pascale Carayon, Shimeng Du, Roger Brown, Randi Cartmill, Mark Johnson, Tosha B Wetterneck
The objective of this study was to describe the frequency, potential harm, and nature of electronic health record (EHR)-related medication errors in intensive care units (ICUs). Using a secondary data analysis of a large database of medication safety events collected in a study on EHR technology in ICUs, we assessed the EHR relatedness of a total of 1622 potential preventable adverse drug events (ADEs) identified in a sample of 624 patients in 2 ICUs of a medical center. Thirty-four percent of the medication events were found to be EHR related...
January 2017: Journal of Healthcare Risk Management: the Journal of the American Society for Healthcare Risk Management
https://www.readbyqxmd.com/read/28099339/pedicle-screw-placement-accuracy-of-bone-mounted-miniature-robot-system
#5
Tai-Hsin Tsai, Rong-Dar Tzou, Yu-Feng Su, Chieh-Hsin Wu, Cheng-Yu Tsai, Chih-Lung Lin
This article describes factors affecting the accuracy of transpedicle screw placements performed with the Renaissance robot-guided system and reviews the relevant literature. Between January 2013 and January 2015, Renaissance robot-guided spinal surgery was performed in 125 patients at Kaohsiung Medical University Hospital in Kaohsiung, Taiwan. The surgeries included 662 transpedicle screw implants and 49 Kirschner wire (K-wire) reimplants performed by intraoperative repositioning. The lead author evaluated the accuracy of all K-wire insertions and classified their accuracy into 3 categories relative to the preoperative plan for transpedicle screw placement...
January 2017: Medicine (Baltimore)
https://www.readbyqxmd.com/read/28099046/death-notification-someone-needs-to-call-the-family
#6
Rachel Ombres, Lauren Montemorano, Daniel Becker
BACKGROUND: The death notification process can affect family grief and bereavement. It can also affect the well-being of involved physicians. There is no standardized process for making death notification phone calls. We assumed that residents are likely to be unprepared before and troubled after. OBJECTIVE: We investigated current death notification practices to develop an evidence-based template for standardizing this process. DESIGN: We used results of a literature review and open-ended interviews with faculty, residents, and widows to develop a survey regarding resident training and experience in death notification by phone...
January 18, 2017: Journal of Palliative Medicine
https://www.readbyqxmd.com/read/28098743/analysis-of-incident-and-accident-reports-and-risk-management-in-spine-surgery
#7
Kazuyoshi Kobayashi, Shiro Imagama, Kei Ando, Tetsuro Hida, Kenyu Ito, Mikito Tsushima, Yoshimoto Ishikawa, Akiyuki Matsumoto, Masayoshi Morozumi, Yoshihiro Nishida, Yoshimasa Nagao, Naoki Ishiguro
STUDY DESIGN: A review of accident and incident reports. OBJECTIVE: To analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery. SUMMARY OF BACKGROUND DATA: In our institution, a clinical error that potentially results in an adverse event is usually submitted as an incident or accident report through a web database, to ensure anonymous and blame-free reporting. All reports are analyzed by a medical safety management group...
January 16, 2017: Spine
https://www.readbyqxmd.com/read/28098592/protocolized-early-sepsis-care-is-not-only-helpful-for-patients-it-prevents-medical-errors
#8
Angel Coz Yataco, Anja Kathrin Jaehne, Emanuel Phillip Rivers
No abstract text is available yet for this article.
January 17, 2017: Critical Care Medicine
https://www.readbyqxmd.com/read/28098496/real-world-adherence-assessment-of-lurasidone-and-other-oral-atypical-antipsychotics-among-patients-with-schizophrenia-an-administrative-claims-analysis
#9
Krithika Rajagopalan, Sally Wade, Nicole Meyer, Antony Loebel
OBJECTIVE: To compare adherence with lurasidone to other oral atypical antipsychotics among Medicaid- and commercially-insured patients with schizophrenia. RESEARCH DESIGN AND METHODS: Administrative claims of patients with schizophrenia treated with atypical antipsychotics (lurasidone, aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone) from October 2010-September 2011 were identified from MarketScan Commercial and Medicaid Databases, and were classified by the first (index) antipsychotic...
January 18, 2017: Current Medical Research and Opinion
https://www.readbyqxmd.com/read/28096019/tinker-tailor-deliberate-an-ethnographic-inquiry-into-the-institutionalized-practice-of-bar-coded-medication-administration-technology-by-nurses
#10
M J M H Boonen, Frans J H Vosman, Alistair R Niemeijer
AIM: Explore the practice of nurses working with bar-coded medication administration technology, to gain insight in the impact it has on their work. BACKGROUND: The widespread presumption of using Barcoded Medication Administration Technology (BCMA) is that it will effectively reduce the number of errors in the dispensing of medication to patients. However, it remains unclear whether this is the case in actual practice. METHOD: Two distinct but overlapping research methodologies of Institutional Ethnography and Praxeology were combined as a means to uncover the highly complex practice of BCMA by nurses...
February 2017: Applied Nursing Research: ANR
https://www.readbyqxmd.com/read/28096015/association-of-medication-errors-with-drug-classifications-clinical-units-and-consequence-of-errors-are-they-related
#11
Maki Muroi, Jay J Shen, Alona Angosta
Registered nurses (RNs) play an important role in safe medication administration and patient safety. This study examined a total of 1276 medication error (ME) incident reports made by RNs in hospital inpatient settings in the southwestern region of the United States. The most common drug class associated with MEs was cardiovascular drugs (24.7%). Among this class, anticoagulants had the most errors (11.3%). The antimicrobials was the second most common drug class associated with errors (19.1%) and vancomycin was the most common antimicrobial that caused errors in this category (6...
February 2017: Applied Nursing Research: ANR
https://www.readbyqxmd.com/read/28095816/awareness-and-knowledge-among-internal-medicine-house-staff-for-dose-adjustment-of-commonly-used-medications-in-patients-with-ckd
#12
Sikander Surana, Neeru Kumar, Amita Vasudeva, Gulvahid Shaikh, Kenar D Jhaveri, Hitesh Shah, Deepa Malieckal, Joshua Fogel, Gurwinder Sidhu, Sofia Rubinstein
BACKGROUND: Drug dosing errors result in adverse patient outcomes and are more common in patients with chronic kidney disease (CKD). As internists treat the majority of patients with CKD, we study if Internal Medicine house-staff have awareness and knowledge about the correct dosage of commonly used medications for those with CKD. METHODS: A cross-sectional survey was performed and included 341 participants. The outcomes were the awareness of whether a medication needs dose adjustment in patients with CKD and whether there was knowledge for the level of glomerular filtration rate (GFR) a medication needs to be adjusted...
January 17, 2017: BMC Nephrology
https://www.readbyqxmd.com/read/28093118/surgical-fires-and-operative-burns-lessons-learned-from-a-33-year-review-of-medical-litigation
#13
Asad J Choudhry, Nadeem N Haddad, Mohammad A Khasawneh, Daniel C Cullinane, Martin D Zielinski
OBJECTIVE: We aimed to understand the setting and litigation outcomes of surgical fires and operative burns. METHODS: Westlaw, an online legal research data-set, was utilized. Data were collected on patient, procedure, and case characteristics. RESULTS: One hundred thirty-nine cases were identified; 114 (82%) operative burns and 25 (18%) surgical fires. Median plaintiff (patient) age was 46 (IQR:28-59). Most common site of operative burn was the face (26% [n = 36])...
December 12, 2016: American Journal of Surgery
https://www.readbyqxmd.com/read/28092846/status-epilepticus-in-patients-with-cirrhosis-how-to-avoid-misdiagnosis-in-patients-with-hepatic-encephalopathy
#14
Marika Rudler, Clémence Marois, Nicolas Weiss, Dominique Thabut, Vincent Navarro
PURPOSE: Status epilepticus (SE) in patients with cirrhosis is a rare but serious situation. Diagnosis may be difficult in emergency presentation, especially when patients present with hepatic encephalopathy (HE). Misdiagnosis must be avoided since some anti-epileptic drugs aggravate HE. In this retrospective study, we therefore assessed the frequency of SE in patients with cirrhosis, evaluated the accuracy of diagnosis and determined rates of mortality. METHOD: We reviewed data from all patients hospitalized from 2005 to 2013 in the Hepatology ICU for complications of cirrhosis with an initial diagnosis of SE...
December 27, 2016: Seizure: the Journal of the British Epilepsy Association
https://www.readbyqxmd.com/read/28092512/a-hidden-markov-model-for-seismocardiography
#15
Johan Wahlstrom, Isaac Skog, Peter Handel, Farzad Khosrow-Khavar, Kouhyar Tavakolian, Phyllis K Stein, Arye Nehorai
We propose a hidden Markov model approach for processing seismocardiograms. The seismocardiogram morphology is learned using the expectation-maximization algorithm, and the state of the heart at a given time instant is estimated by the Viterbi algorithm. From the obtained Viterbi sequence, it is then straightforward to estimate instantaneous heart rate, heart rate variability measures, and cardiac time intervals (the latter requiring a small number of manual annotations). As is shown in the conducted experimental study, the presented algorithm outperforms the state-of-the-art in seismocardiogrambased heart rate and heart rate variability estimation Moreover, the isovolumic contraction time and the left ventricular ejection time are estimated with mean absolute errors of about 5 [ms] and 9 [ms], respectively...
January 9, 2017: IEEE Transactions on Bio-medical Engineering
https://www.readbyqxmd.com/read/28090164/a-comparison-of-medication-histories-obtained-by-a-pharmacy-technician-versus-nurses-in-the-emergency-department
#16
Marija Markovic, A Scott Mathis, Hoytin Lee Ghin, Michelle Gardiner, Germin Fahim
PURPOSE: To compare the medication history error rate of the emergency department (ED) pharmacy technician with that of nursing staff and to describe the workflow environment. METHODS: Fifty medication histories performed by an ED nurse followed by the pharmacy technician were evaluated for discrepancies (RN-PT group). A separate 50 medication histories performed by the pharmacy technician and observed with necessary intervention by the ED pharmacist were evaluated for discrepancies (PT-RPh group)...
January 2017: P & T: a Peer-reviewed Journal for Formulary Management
https://www.readbyqxmd.com/read/28088795/influence-of-intracranial-air-on-electrode-position-and-clinical-outcomes-following-deep-brain-stimulation-for-parkinson-s-disease
#17
J Nicole Bentley, Zhe Guan, Karen S Cummings, Kelvin L Chou, Parag G Patil
BACKGROUND: The introduction of intracranial air during deep brain stimulation (DBS) surgery is believed to negatively impact targeting accuracy and clinical outcomes. OBJECTIVE: To quantify the relationship between intracranial air (ICA) volumes, targeting accuracy, and clinical outcomes in patients undergoing subthalamic nucleus (STN) DBS for Parkinson's disease. METHODS: ICA in 73 consecutive STN DBS cases (146 leads) was measured by high-resolution CT and correlated with proximal lead bowing, electrode displacement, targeting accuracy, and clinical outcomes at 6 and 12 months...
January 14, 2017: Stereotactic and Functional Neurosurgery
https://www.readbyqxmd.com/read/28088628/methods-needed-to-measure-predictive-accuracy-a-study-of-diabetic-patients
#18
Hafiz M R Khan, Sarah Mende, Aamrin Rafiq, Kemesha Gabbidon, P Hemachandra Reddy
Diabetes is one of the leading causes of morbidity and mortality and it can result in several complications such as kidney failure, heart failure, stroke, and blindness making it a major medical and public health concern in the United States. Statistical methods are important to detect risk factors and identify the best sampling plan to determine predictive bounds for diabetic patients' data. The main objective of this paper is to identify the best fit bootstrapping sampling method and to draw the predictive bound considering diabetes patient data...
January 11, 2017: Biochimica et Biophysica Acta
https://www.readbyqxmd.com/read/28088527/navigation-in-the-electronic-health-record-a-review-of-the-safety-and-usability-literature
#19
REVIEW
Lisette C Roman, Jessica S Ancker, Stephen B Johnson, Yalini Senathirajah
OBJECTIVE: Inefficient navigation in electronic health records has been shown to increase users' cognitive load, which may increase potential for errors, reduce efficiency, and increase fatigue. However, navigation has received insufficient recognition and attention in the electronic health record (EHR) literature as an independent construct and contributor to overall usability. Our aims in this literature review were to (1) assess the prevalence of navigation-related topics within the EHR usability and safety research literature, (2) categorize types of navigation actions within the EHR, (3) capture relationships between these navigation actions and usability principles, and (4) collect terms and concepts related to EHR navigation...
January 11, 2017: Journal of Biomedical Informatics
https://www.readbyqxmd.com/read/28087554/how-prepared-are-uk-medical-graduates-for-practice-a-rapid-review-of-the-literature-2009-2014
#20
Lynn V Monrouxe, Lisa Grundy, Mala Mann, Zoe John, Eleni Panagoulas, Alison Bullock, Karen Mattick
OBJECTIVE: To understand how prepared UK medical graduates are for practice and the effectiveness of workplace transition interventions. DESIGN: A rapid review of the literature (registration #CRD42013005305). DATA SOURCES: Nine major databases (and key websites) were searched in two timeframes (July-September 2013; updated May-June 2014): CINAHL, Embase, Educational Resources Information Centre, Health Management Information Consortium, MEDLINE, MEDLINE in Process, PsycINFO, Scopus and Web of Knowledge...
January 13, 2017: BMJ Open
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