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medication errors reporting

Brian Shiner, Christine Leonard Westgate, Vanessa Simiola, Richard Thompson, Paula P Schnurr, Joan M Cook
Objective: Available studies on implementation of evidence-based psychotherapy (EBP) for patients attending Department of Veterans Affairs (VA) residential post-traumatic stress disorder (PTSD) programs rely on therapist self-report of EBP delivery. Patient-level data on receipt of EBP are needed both to corroborate therapist self-report and to understand patient factors that predict receipt of EBPs for PTSD. Materials and Methods: We identified 159 therapists from 38 VA residential PTSD programs who responded to a survey about EBP implementation during the 2015 fiscal year (FY15)...
March 14, 2018: Military Medicine
Pavani Rangachari
In 1999, the Institute of Medicine reported that 98,000 people die each year due to medical errors. In the following years, the focus on hospital quality was intensified nationally, with policymakers providing evidence-based practice guidelines for improving health care quality. However, these innovations (evidence-based guidelines) that were being produced at policy levels were not translating to clinical practice at the hospital organizational level easily, and stark variations continued to persist, in the quality of health care...
2018: Innov Entrep Health
Louise Ramsden, Martin Patrick McColgan, Thomas Rossor, Anne Greenough, Simon J Clark
Studies of adult patients have demonstrated that weekend admissions compared with weekday admissions had a significantly higher hospital mortality rate. We have reviewed the literature to determine if the timing of admission, for example, weekend or weekday, influenced mortality and morbidity in children. Seventeen studies reported the effect of timing of admission on mortality, and only four studies demonstrated an increase in those admitted at the weekend. Meta-analysis of the results of 15 of the studies demonstrated there was no significant weekend effect...
March 15, 2018: Archives of Disease in Childhood
Jane K O'Hara, Caroline Reynolds, Sally Moore, Gerry Armitage, Laura Sheard, Claire Marsh, Ian Watt, John Wright, Rebecca Lawton
BACKGROUND: Patient safety measurement remains a global challenge. Patients are an important but neglected source of learning; however, little is known about what patients can add to our understanding of safety. We sought to understand the incidence and nature of patient-reported safety concerns in hospital. METHODS: Feedback about the experience of safety within hospital was gathered from 2471 inpatients as part of a multicentre, waitlist cluster randomised controlled trial of an intervention, undertaken within 33 wards across three English NHS Trusts, between May 2013 and September 2014...
March 15, 2018: BMJ Quality & Safety
Sara L Ackerman, Gato Gourley, Gem Le, Pamela Williams, Jinoos Yazdany, Urmimala Sarkar
OBJECTIVE: The aim of the study was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems. METHODS: Leaders from five California safety net health systems were invited to participate in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute in 2016. During each of the three Delphi rounds, the feasibility and validity of 13 proposed patient safety measures were discussed and prioritized...
March 14, 2018: Journal of Patient Safety
Renata C Gallagher, Laura Pollard, Anna I Scott, Suzette Huguenin, Stephen Goodman, Qin Sun
Disclaimer: These ACMG Standards are intended as an educational resource for clinical laboratory geneticists to help them provide quality clinical laboratory genetic services. Adherence to these Standards is voluntary and does not necessarily assure a successful medical outcome. These Standards should not be considered inclusive of all proper procedures and tests, or exclusive of others that are reasonably directed to obtaining the same results. In determining the propriety of any specific procedure or test, clinical laboratory geneticists should apply their professional judgment to the specific circumstances presented by the patient or specimen...
March 15, 2018: Genetics in Medicine: Official Journal of the American College of Medical Genetics
D A van Riet-Nales, E D Nijholt-Faber, A de Boer
The Netherlands Medicines Evaluation Board (MEB) was recently informed about a serious pipamperone overdose in a 6-year-old boy, which happened because the boy was given the medication in streams rather than in drops. This article describes the use of drops in pharmaceutical patient care and explains why the MEB has maintained marketing authorization for the product on the basis of currently available information. The MEB urgently requests the healthcare professional groups to report all problems concerning drug use to the Netherlands Pharmacovigilance Centre Lareb, and the Portal for Patient Safety; this is the only way in which it can be verified whether incidental medication errors are actually, and continue to be, incidental...
2018: Nederlands Tijdschrift Voor Geneeskunde
J H C de Roo, T M Bosch, A van Rhijn, R Del Canho
BACKGROUND: Medication is not always delivered in a safe dosing format. Up to 33% of medication errors can be attributed to confusing packaging or labelling. CASE DESCRIPTION: A 6-year-old boy with ADHD, for which he was being treated with methylphenidate and pipamperone drops, was brought to the A&E department with signs of severe encephalopathy. He had apparently been given pipamperone in streams rather than in drops in the previous months. The pipamperone level in his blood was raised to toxic levels...
2018: Nederlands Tijdschrift Voor Geneeskunde
(no author information available yet)
OBJECTIVES: To ascertain the proportion of neonates and infants presenting with suspicion of an inborn error of metabolism in the centers identified by ICMR for newborn screening. METHODS: A set of red flag signs suggestive IEM were listed by the Taskforce members. The age group was limited to one year as it was understood that most of the small molecules with a severe phenotype would present before the age of one year. Further investigations were tandem mass spectrometry, gas chromatography mass spectrometry and high performance liquid chromatography...
March 15, 2018: Indian Journal of Pediatrics
Isabel Kiesewetter, Karen D Könings, Moritz Kager, Jan Kiesewetter
OBJECTIVES: In undergraduate medical education, the topics of errors in medicine and patient safety are under-represented. The aim of this study was to explore undergraduate medical students' behavioural intentions when confronted with an error. DESIGN: A qualitative case vignette survey was conducted including one of six randomly distributed case scenarios in which a hypothetical but realistic medical error occurred. The six scenarios differed regarding (1) who caused the error, (2) the presence of witnesses and (3) the consequences of the error for the patient...
March 14, 2018: BMJ Open
Bibb Allen, Mythreyi Chatfield, Judy Burleson, William T Thorwarth
In September of 2014, the American College of Radiology joined a number of other organizations in sponsoring the 2015 National Academy of Medicine report, Improving Diagnosis In Health Care. Our presentation to the Academy emphasized that although diagnostic errors in imaging are commonly considered to result only from failures in disease detection or misinterpretation of a perceived abnormality, most errors in diagnosis result from failures in information gathering, aggregation, dissemination and ultimately integration of that information into our patients' clinical problems...
September 26, 2017: Diagnosis
Veronica Restelli, Annemarie Taylor, Douglas Cochrane, Michael A Noble
BACKGROUND: This article reports on the findings of 12,278 laboratory related safety events that were reported through the British Columbia Patient Safety & Learning System Incident Reporting System. METHODS: The reports were collected from 75 hospital-based laboratories over a 33-month period and represent approximately 4.9% of all incidents reported. RESULTS: Consistent with previous studies 76% of reported incidents occurred during the pre-analytic phase of the laboratory cycle, with twice as many associated with collection problems as with clerical problems...
June 27, 2017: Diagnosis
Pierre Antoine Brown, Swapnil Hiremath, Edward G Clark, Edmund S H Kwok, Christopher McCudden, Ayub Akbari
BACKGROUND: Morbidity and Mortality Conferences (M&MCs) have for generations been part of the education of physicians, yet their effectiveness remains questionable. The Ottawa M&M Model (OM3) was developed to provide a structured approach to M&MCs in order to maximize the quality improvement impact of such rounds. STUDY DESIGN: We conducted a retrospective assessment of the impact of implementing nephrology-specific M&MCs using the OM3. SETTING AND PARTICIPANTS: All physicians, residents and fellows from the division of nephrology at a large academic medical center were invited to participate...
March 12, 2018: International Urology and Nephrology
Carmen Canovas, Aixa Alarcon, Robert Rosén, Sanjeev Kasthurirangan, Joseph J K Ma, Douglas D Koch, Patricia Piers
PURPOSE: To assess the accuracy of toric intraocular lens (IOL) power calculations of a new algorithm that incorporates the effect of posterior corneal astigmatism (PCA). SETTING: Abbott Medical Optics, Inc., Groningen, the Netherlands. DESIGN: Retrospective case report. METHODS: In eyes implanted with toric IOLs, the exact vergence formula of the Tecnis toric calculator was used to predict refractive astigmatism from preoperative biometry, surgeon-estimated surgically induced astigmatism (SIA), and implanted IOL power, with and without including the new PCA algorithm...
March 7, 2018: Journal of Cataract and Refractive Surgery
Honghong Zou, Baoqin Zhou, Gaosi Xu
Following publication of the original article [1] the authors reported that the first affiliation ("Medical Center of the Graduate School, Nanchang University, China") had been added in error, and that the correct author information is as given in this erratum.
March 9, 2018: Cardiovascular Diabetology
Eric P Brass, Kate M Reynolds, Randy I Burnham, Jody L Green
OBJECTIVE: The impact of the 2011 changes in pediatric single ingredient liquid acetaminophen product packaging and standardization of the acetaminophen concentration (160 mg/5 mL) on poison center exposures due to medication errors was assessed. METHODS: National Poison Data System (NPDS) data from January 1, 2007 through December 31, 2016 were used to identify medication error exposures involving single ingredient liquid acetaminophen in children less than 12 years of age...
March 6, 2018: Academic Pediatrics
Timo B Brakenhoff, Marian Mitroiu, Ruth H Keogh, Karel G M Moons, Rolf H H Groenwold, Maarten van Smeden
In medical research, covariates (e.g. exposure and confounder variables) are often measured with error. While it is well accepted that this introduces bias and imprecision in exposure-outcome relations, it is unclear to what extent such issues are currently considered in research practice. The objective was to study common practices regarding covariate measurement error via a systematic review of general medicine and epidemiology literature. Original research published in 2016 in 12 high impact journals was full-text searched for phrases relating to measurement error...
March 6, 2018: Journal of Clinical Epidemiology
E Jair Vidal, Daily Alvarez, Dalia Martinez-Velarde, Lorena Vidal-Damas, Kelly A Yuncar-Rojas, Alesia Julca-Malca, Antonio Bernabe-Ortiz
OBJECTIVES: Different studies have reported the association between perceived stress and unhealthy diet choices. We aimed to determine whether there is a relationship between perceived stress and fat intake among undergraduate medical students. METHODS/PRINCIPAL FINDINGS: A cross-sectional study was performed including first-year medical students. The outcome of interest was the self-report of fat intake assessed using the Block Screening Questionnaire for Fat Intake (high vs...
2018: PloS One
Naqash J Sethi, Emil E Nielsen, Sanam Safi, Joshua Feinberg, Christian Gluud, Janus C Jakobsen
BACKGROUND: During recent years, systematic reviews of observational studies have compared digoxin to no digoxin in patients with atrial fibrillation or atrial flutter, and the results of these reviews suggested that digoxin seems to increase the risk of all-cause mortality regardless of concomitant heart failure. Our objective was to assess the benefits and harms of digoxin for atrial fibrillation and atrial flutter based on randomized clinical trials. METHODS: We searched CENTRAL, MEDLINE, Embase, LILACS, SCI-Expanded, BIOSIS for eligible trials comparing digoxin versus placebo, no intervention, or other medical interventions in patients with atrial fibrillation or atrial flutter in October 2016...
2018: PloS One
Rajeswari Swaminathan, Yungui Huang, Katherine Miller, Matthew Pastore, Sayaka Hashimoto, Theodora Jacobson, Danielle Mouhlas, Simon Lin
The adoption rate of genome sequencing for clinical diagnostics has been steadily increasing leading to the possibility of improvement in diagnostic yields. Although laboratories generate a summary clinical report, sharing raw genomic data with healthcare providers is equally important, both for secondary research studies as well as for a deeper analysis of the data itself, as seen by the efforts from organizations such as American College of Medical Genetics and Genomics and Global Alliance for Genomics and Health...
2018: Frontiers in Genetics
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