Ad hoc versus standardized admixtures for continuous infusion drugs in neonatal intensive care: cognitive task analysis of safety at the bedside.

PubMed

Brannon, Timothy S

2006-01-01

Continuous infusion intravenous (IV) drugs in neonatal intensive care are usually prepared based on patient weight so that the dose is readable as a simple multiple of the infusion pump rate. New safety guidelines propose that hospitals switch to using standardized admixtures of these drugs to prevent calculation errors during ad hoc preparation. Extended hierarchical task analysis suggests that switching to standardized admixtures may lead to more errors in programming the pump at the bedside.

Ad Hoc versus Standardized Admixtures for Continuous Infusion Drugs in Neonatal Intensive Care: Cognitive Task Analysis of Safety at the Bedside

PubMed Central

Brannon, Timothy S.

2006-01-01

Continuous infusion intravenous (IV) drugs in neonatal intensive care are usually prepared based on patient weight so that the dose is readable as a simple multiple of the infusion pump rate. New safety guidelines propose that hospitals switch to using standardized admixtures of these drugs to prevent calculation errors during ad hoc preparation. Extended hierarchical task analysis suggests that switching to standardized admixtures may lead to more errors in programming the pump at the bedside. PMID:17238482

[Management of medication errors in general medical practice: Study in a pluriprofessionnal health care center].

PubMed

Pourrain, Laure; Serin, Michel; Dautriche, Anne; Jacquetin, Fréderic; Jarny, Christophe; Ballenecker, Isabelle; Bahous, Mickaël; Sgro, Catherine

2018-06-07

Medication errors are the most frequent medical care adverse events in France. Their management process used in hospital remains poorly applied in primary ambulatory care. The main objective of our study was to assess medication error management in general ambulatory practice. The secondary objectives were the characterization of the errors and the analysis of their root causes in order to implement corrective measures. The study was performed in a pluriprofessionnal health care house, applying the stages and tools validated by the French high health authority, that we previously adapted to ambulatory medical cares. During the 3 months study 4712 medical consultations were performed and we collected 64 medication errors. Most of affected patients were at the extreme ages of life (9,4 % before 9 years and 64 % after 70 years). Medication errors occurred at home in 39,1 % of cases, at pluriprofessionnal health care house (25,0 %) or at drugstore (17,2 %). They led to serious clinical consequences (classified as major, critical or catastrophic) in 17,2 % of cases. Drug induced adverse effects occurred in 5 patients, 3 of them needing hospitalization (1 patient recovered, 1 displayed sequelae and 1 died). In more than half of cases, the errors occurred at prescribing stage. The most frequent type of errors was the use of a wrong drug, different from that indicated for the patient (37,5 %) and poor treatment adherence (18,75 %). The systemic reported causes were a care process dysfunction (in coordination or procedure), the health care action context (patient home, not planned act, professional overwork), human factors such as patient and professional condition. The professional team adherence to the study was excellent. Our study demonstrates, for the first time in France, that medication errors management in ambulatory general medical care can be implemented in a pluriprofessionnal health care house with two conditions: the presence of a trained team coordinator, and the use of validated adapted and simple processes and tools. This study also shows that medications errors in general practice are specific of the care process organization. We identified vulnerable points, as transferring and communication between home and care facilities or conversely, medical coordination and involvement of the patient himself in his care. Copyright © 2018 Société française de pharmacologie et de thérapeutique. Published by Elsevier Masson SAS. All rights reserved.

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

PubMed

Wagar, Elizabeth A; Tamashiro, Lorraine; Yasin, Bushra; Hilborne, Lee; Bruckner, David A

2006-11-01

Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process. To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools. Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics. Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months. Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.

Assessing primary care data quality.

PubMed

Lim, Yvonne Mei Fong; Yusof, Maryati; Sivasampu, Sheamini

2018-04-16

Purpose The purpose of this paper is to assess National Medical Care Survey data quality. Design/methodology/approach Data completeness and representativeness were computed for all observations while other data quality measures were assessed using a 10 per cent sample from the National Medical Care Survey database; i.e., 12,569 primary care records from 189 public and private practices were included in the analysis. Findings Data field completion ranged from 69 to 100 per cent. Error rates for data transfer from paper to web-based application varied between 0.5 and 6.1 per cent. Error rates arising from diagnosis and clinical process coding were higher than medication coding. Data fields that involved free text entry were more prone to errors than those involving selection from menus. The authors found that completeness, accuracy, coding reliability and representativeness were generally good, while data timeliness needs to be improved. Research limitations/implications Only data entered into a web-based application were examined. Data omissions and errors in the original questionnaires were not covered. Practical implications Results from this study provided informative and practicable approaches to improve primary health care data completeness and accuracy especially in developing nations where resources are limited. Originality/value Primary care data quality studies in developing nations are limited. Understanding errors and missing data enables researchers and health service administrators to prevent quality-related problems in primary care data.

Risk behaviours for organism transmission in health care delivery-A two month unstructured observational study.

PubMed

Lindberg, Maria; Lindberg, Magnus; Skytt, Bernice

2017-05-01

Errors in infection control practices risk patient safety. The probability for errors can increase when care practices become more multifaceted. It is therefore fundamental to track risk behaviours and potential errors in various care situations. The aim of this study was to describe care situations involving risk behaviours for organism transmission that could lead to subsequent healthcare-associated infections. Unstructured nonparticipant observations were performed at three medical wards. Healthcare personnel (n=27) were shadowed, in total 39h, on randomly selected weekdays between 7:30 am and 12 noon. Content analysis was used to inductively categorize activities into tasks and based on the character into groups. Risk behaviours for organism transmission were deductively classified into types of errors. Multiple response crosstabs procedure was used to visualize the number and proportion of errors in tasks. One-Way ANOVA with Bonferroni post Hoc test was used to determine differences among the three groups of activities. The qualitative findings gives an understanding of that risk behaviours for organism transmission goes beyond the five moments of hand hygiene and also includes the handling and placement of materials and equipment. The tasks with the highest percentage of errors were; 'personal hygiene', 'elimination' and 'dressing/wound care'. The most common types of errors in all identified tasks were; 'hand disinfection', 'glove usage', and 'placement of materials'. Significantly more errors (p<0.0001) were observed the more multifaceted (single, combined or interrupted) the activity was. The numbers and types of errors as well as the character of activities performed in care situations described in this study confirm the need to improve current infection control practices. It is fundamental that healthcare personnel practice good hand hygiene however effective preventive hygiene is complex in healthcare activities due to the multifaceted care situations, especially when activities are interrupted. A deeper understanding of infection control practices that goes beyond the sense of security by means of hand disinfection and use of gloves is needed as materials and surfaces in the care environment might be contaminated and thus pose a risk for organism transmission. Copyright © 2017 Elsevier Ltd. All rights reserved.

Medication prescribing errors in the medical intensive care unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

PubMed

Sada, Oumer; Melkie, Addisu; Shibeshi, Workineh

2015-09-16

Medication errors (MEs) are important problems in all hospitalized populations, especially in intensive care unit (ICU). Little is known about the prevalence of medication prescribing errors in the ICU of hospitals in Ethiopia. The aim of this study was to assess medication prescribing errors in the ICU of Tikur Anbessa Specialized Hospital using retrospective cross-sectional analysis of patient cards and medication charts. About 220 patient charts were reviewed with a total of 1311 patient-days, and 882 prescription episodes. 359 MEs were detected; with prevalence of 40 per 100 orders. Common prescribing errors were omission errors 154 (42.89%), 101 (28.13%) wrong combination, 48 (13.37%) wrong abbreviation, 30 (8.36%) wrong dose, wrong frequency 18 (5.01%) and wrong indications 8 (2.23%). The present study shows that medication errors are common in medical ICU of Tikur Anbessa Specialized Hospital. These results suggest future targets of prevention strategies to reduce the rate of medication error.

A preliminary taxonomy of medical errors in family practice

PubMed Central

Dovey, S; Meyers, D; Phillips, R; Green, L; Fryer, G; Galliher, J; Kappus, J; Grob, P

2002-01-01

Objective: To develop a preliminary taxonomy of primary care medical errors. Design: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. Setting: The National Network for Family Practice and Primary Care Research. Participants: Family physicians. Main outcome measures: Medical error category, context, and consequence. Results: Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failures (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. Conclusions: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors. PMID:12486987

A preliminary taxonomy of medical errors in family practice.

PubMed

Dovey, S M; Meyers, D S; Phillips, R L; Green, L A; Fryer, G E; Galliher, J M; Kappus, J; Grob, P

2002-09-01

To develop a preliminary taxonomy of primary care medical errors. Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. The National Network for Family Practice and Primary Care Research. Family physicians. Medical error category, context, and consequence. Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Robust Linear Models for Cis-eQTL Analysis.

PubMed

Rantalainen, Mattias; Lindgren, Cecilia M; Holmes, Christopher C

2015-01-01

Expression Quantitative Trait Loci (eQTL) analysis enables characterisation of functional genetic variation influencing expression levels of individual genes. In outbread populations, including humans, eQTLs are commonly analysed using the conventional linear model, adjusting for relevant covariates, assuming an allelic dosage model and a Gaussian error term. However, gene expression data generally have noise that induces heavy-tailed errors relative to the Gaussian distribution and often include atypical observations, or outliers. Such departures from modelling assumptions can lead to an increased rate of type II errors (false negatives), and to some extent also type I errors (false positives). Careful model checking can reduce the risk of type-I errors but often not type II errors, since it is generally too time-consuming to carefully check all models with a non-significant effect in large-scale and genome-wide studies. Here we propose the application of a robust linear model for eQTL analysis to reduce adverse effects of deviations from the assumption of Gaussian residuals. We present results from a simulation study as well as results from the analysis of real eQTL data sets. Our findings suggest that in many situations robust models have the potential to provide more reliable eQTL results compared to conventional linear models, particularly in respect to reducing type II errors due to non-Gaussian noise. Post-genomic data, such as that generated in genome-wide eQTL studies, are often noisy and frequently contain atypical observations. Robust statistical models have the potential to provide more reliable results and increased statistical power under non-Gaussian conditions. The results presented here suggest that robust models should be considered routinely alongside other commonly used methodologies for eQTL analysis.

Development and Assessment of a Medication Safety Measurement Program in a Long-Term Care Pharmacy.

PubMed

Hertig, John B; Hultgren, Kyle E; Parks, Scott; Rondinelli, Rick

2016-02-01

Medication errors continue to be a major issue in the health care system, including in long-term care facilities. While many hospitals and health systems have developed methods to identify, track, and prevent these errors, long-term care facilities historically have not invested in these error-prevention strategies. The objective of this study was two-fold: 1) to develop a set of medication-safety process measures for dispensing in a long-term care pharmacy, and 2) to analyze the data from those measures to determine the relative safety of the process. The study was conducted at In Touch Pharmaceuticals in Valparaiso, Indiana. To assess the safety of the medication-use system, each step was documented using a comprehensive flowchart (process flow map) tool. Once completed and validated, the flowchart was used to complete a "failure modes and effects analysis" (FMEA) identifying ways a process may fail. Operational gaps found during FMEA were used to identify points of measurement. The research identified a set of eight measures as potential areas of failure; data were then collected on each one of these. More than 133,000 medication doses (opportunities for errors) were included in the study during the research time frame (April 1, 2014, and ended on June 4, 2014). Overall, there was an approximate order-entry error rate of 15.26%, with intravenous errors at 0.37%. A total of 21 errors migrated through the entire medication-use system. These 21 errors in 133,000 opportunities resulted in a final check error rate of 0.015%. A comprehensive medication-safety measurement program was designed and assessed. This study demonstrated the ability to detect medication errors in a long-term pharmacy setting, thereby making process improvements measureable. Future, larger, multi-site studies should be completed to test this measurement program.

Blood specimen labelling errors: Implications for nephrology nursing practice.

PubMed

Duteau, Jennifer

2014-01-01

Patient safety is the foundation of high-quality health care, as recognized both nationally and worldwide. Patient blood specimen identification is critical in ensuring the delivery of safe and appropriate care. The practice of nephrology nursing involves frequent patient blood specimen withdrawals to treat and monitor kidney disease. A critical review of the literature reveals that incorrect patient identification is one of the major causes of blood specimen labelling errors. Misidentified samples create a serious risk to patient safety leading to multiple specimen withdrawals, delay in diagnosis, misdiagnosis, incorrect treatment, transfusion reactions, increased length of stay and other negative patient outcomes. Barcode technology has been identified as a preferred method for positive patient identification leading to a definitive decrease in blood specimen labelling errors by as much as 83% (Askeland, et al., 2008). The use of a root cause analysis followed by an action plan is one approach to decreasing the occurrence of blood specimen labelling errors. This article will present a review of the evidence-based literature surrounding blood specimen labelling errors, followed by author recommendations for completing a root cause analysis and action plan. A failure modes and effects analysis (FMEA) will be presented as one method to determine root cause, followed by the Ottawa Model of Research Use (OMRU) as a framework for implementation of strategies to reduce blood specimen labelling errors.

The culture of patient safety in an Iranian intensive care unit.

PubMed

Abdi, Zhaleh; Delgoshaei, Bahram; Ravaghi, Hamid; Abbasi, Mohsen; Heyrani, Ali

2015-04-01

To explore nurses' and physicians' attitudes and perceptions relevant to safety culture and to elicit strategies to promote safety culture in an intensive care unit. A strong safety culture is essential to ensure patient safety in the intensive care unit. This case study adopted a mixed method design. The Safety Attitude Questionnaire (SAQ-ICU version), assessing the safety climate through six domains, was completed by nurses and physicians (n = 42) in an academic intensive care unit. Twenty semi-structured interviews and document analyses were conducted as well. Interviews were analysed using a framework analysis method. Mean scores across the six domains ranged from 52.3 to 72.4 on a 100-point scale. Further analysis indicated that there were statistically significant differences between physicians' and nurses' attitudes toward teamwork (mean scores: 64.5/100 vs. 52.6/100, d = 1.15, t = 3.69, P < 0.001) and job satisfaction (mean scores: 78.2/100 vs. 57.7/100, d = 1.5, t = 4.8, P < 0.001). Interviews revealed several safety challenges including underreporting, failure to learn from errors, lack of speaking up, low job satisfaction among nurses and ineffective nurse-physician communication. The results indicate that all the domains need improvements. However, further attention should be devoted to error reporting and analysis, communication and teamwork among professional groups, and nurses' job satisfaction. Nurse managers can contribute to promoting a safety culture by encouraging staff to report errors, fostering learning from errors and addressing inter-professional communication problems. © 2013 John Wiley & Sons Ltd.

Inpatient medical errors involving glucose-lowering medications and their impact on patients: review of 2,598 incidents from a voluntary electronic error-reporting database.

PubMed

Amori, Renee E; Pittas, Anastassios G; Siegel, Richard D; Kumar, Sanjaya; Chen, Jack S; Karnam, Suneel; Golden, Sherita H; Salem, Deeb N

2008-01-01

To describe characteristics of inpatient medical errors involving hypoglycemic medications and their impact on patient care. We conducted a cross-sectional analysis of medical errors and associated adverse events voluntarily reported by hospital employees and staff in 21 nonprofit, nonfederal health-care organizations in the United States that implemented a Web-based electronic error-reporting system (e-ERS) between August 1, 2000, and December 31, 2005. Persons reporting the errors determined the level of impact on patient care. The median duration of e-ERS use was 3.1 years, and 2,598 inpatient error reports involved insulin or orally administered hypoglycemic agents. Nursing staff provided 59% of the reports; physicians reported <2%. Approximately two-thirds of the errors (1,693 of 2,598) reached the patient. Errors that caused temporary harm necessitating major treatment or that caused permanent harm accounted for 1.5% of reports (40 of 2,598). Insulin was involved in 82% of reports, and orally administered hypoglycemic agents were involved in 18% of all reports (473 of 2,598). Sulfonylureas were implicated in 51.8% of reports involving oral hypoglycemic agents (9.4% of all reports). An e-ERS provides an accessible venue for reporting and tracking inpatient medical errors involving glucose-lowering medications. Results are limited by potential underreporting of events, particularly by physicians, and variations in the reporter perception of patient harm.

Antidepressant and antipsychotic medication errors reported to United States poison control centers.

PubMed

Kamboj, Alisha; Spiller, Henry A; Casavant, Marcel J; Chounthirath, Thitphalak; Hodges, Nichole L; Smith, Gary A

2018-05-08

To investigate unintentional therapeutic medication errors associated with antidepressant and antipsychotic medications in the United States and expand current knowledge on the types of errors commonly associated with these medications. A retrospective analysis of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications was conducted using data from the National Poison Data System. From 2000 to 2012, poison control centers received 207 670 calls reporting unintentional therapeutic errors associated with antidepressant or antipsychotic medications that occurred outside of a health care facility, averaging 15 975 errors annually. The rate of antidepressant-related errors increased by 50.6% from 2000 to 2004, decreased by 6.5% from 2004 to 2006, and then increased 13.0% from 2006 to 2012. The rate of errors related to antipsychotic medications increased by 99.7% from 2000 to 2004 and then increased by 8.8% from 2004 to 2012. Overall, 70.1% of reported errors occurred among adults, and 59.3% were among females. The medications most frequently associated with errors were selective serotonin reuptake inhibitors (30.3%), atypical antipsychotics (24.1%), and other types of antidepressants (21.5%). Most medication errors took place when an individual inadvertently took or was given a medication twice (41.0%), inadvertently took someone else's medication (15.6%), or took the wrong medication (15.6%). This study provides a comprehensive overview of non-health care facility unintentional therapeutic errors associated with antidepressant and antipsychotic medications. The frequency and rate of these errors increased significantly from 2000 to 2012. Given that use of these medications is increasing in the US, this study provides important information about the epidemiology of the associated medication errors. Copyright © 2018 John Wiley & Sons, Ltd.

Your Health Care May Kill You: Medical Errors.

PubMed

Anderson, James G; Abrahamson, Kathleen

2017-01-01

Recent studies of medical errors have estimated errors may account for as many as 251,000 deaths annually in the United States (U.S)., making medical errors the third leading cause of death. Error rates are significantly higher in the U.S. than in other developed countries such as Canada, Australia, New Zealand, Germany and the United Kingdom (U.K). At the same time less than 10 percent of medical errors are reported. This study describes the results of an investigation of the effectiveness of the implementation of the MEDMARX Medication Error Reporting system in 25 hospitals in Pennsylvania. Data were collected on 17,000 errors reported by participating hospitals over a 12-month period. Latent growth curve analysis revealed that reporting of errors by health care providers increased significantly over the four quarters. At the same time, the proportion of corrective actions taken by the hospitals remained relatively constant over the 12 months. A simulation model was constructed to examine the effect of potential organizational changes resulting from error reporting. Four interventions were simulated. The results suggest that improving patient safety requires more than voluntary reporting. Organizational changes need to be implemented and institutionalized as well.

Executive Council lists and general practitioner files

PubMed Central

Farmer, R. D. T.; Knox, E. G.; Cross, K. W.; Crombie, D. L.

1974-01-01

An investigation of the accuracy of general practitioner and Executive Council files was approached by a comparison of the two. High error rates were found, including both file errors and record errors. On analysis it emerged that file error rates could not be satisfactorily expressed except in a time-dimensioned way, and we were unable to do this within the context of our study. Record error rates and field error rates were expressible as proportions of the number of records on both the lists; 79·2% of all records exhibited non-congruencies and particular information fields had error rates ranging from 0·8% (assignation of sex) to 68·6% (assignation of civil state). Many of the errors, both field errors and record errors, were attributable to delayed updating of mutable information. It is concluded that the simple transfer of Executive Council lists to a computer filing system would not solve all the inaccuracies and would not in itself permit Executive Council registers to be used for any health care applications requiring high accuracy. For this it would be necessary to design and implement a purpose designed health care record system which would include, rather than depend upon, the general practitioner remuneration system. PMID:4816588

Diagnostic Errors in Ambulatory Care: Dimensions and Preventive Strategies

ERIC Educational Resources Information Center

Singh, Hardeep; Weingart, Saul N.

2009-01-01

Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may…

Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency.

PubMed

Siewert, Bettina; Brook, Olga R; Hochman, Mary; Eisenberg, Ronald L

2016-03-01

The purpose of this study is to analyze the impact of communication errors on patient care, customer satisfaction, and work-flow efficiency and to identify opportunities for quality improvement. We performed a search of our quality assurance database for communication errors submitted from August 1, 2004, through December 31, 2014. Cases were analyzed regarding the step in the imaging process at which the error occurred (i.e., ordering, scheduling, performance of examination, study interpretation, or result communication). The impact on patient care was graded on a 5-point scale from none (0) to catastrophic (4). The severity of impact between errors in result communication and those that occurred at all other steps was compared. Error evaluation was performed independently by two board-certified radiologists. Statistical analysis was performed using the chi-square test and kappa statistics. Three hundred eighty of 422 cases were included in the study. One hundred ninety-nine of the 380 communication errors (52.4%) occurred at steps other than result communication, including ordering (13.9%; n = 53), scheduling (4.7%; n = 18), performance of examination (30.0%; n = 114), and study interpretation (3.7%; n = 14). Result communication was the single most common step, accounting for 47.6% (181/380) of errors. There was no statistically significant difference in impact severity between errors that occurred during result communication and those that occurred at other times (p = 0.29). In 37.9% of cases (144/380), there was an impact on patient care, including 21 minor impacts (5.5%; result communication, n = 13; all other steps, n = 8), 34 moderate impacts (8.9%; result communication, n = 12; all other steps, n = 22), and 89 major impacts (23.4%; result communication, n = 45; all other steps, n = 44). In 62.1% (236/380) of cases, no impact was noted, but 52.6% (200/380) of cases had the potential for an impact. Among 380 communication errors in a radiology department, 37.9% had a direct impact on patient care, with an additional 52.6% having a potential impact. Most communication errors (52.4%) occurred at steps other than result communication, with similar severity of impact.

Medication errors in residential aged care facilities: a distributed cognition analysis of the information exchange process.

PubMed

Tariq, Amina; Georgiou, Andrew; Westbrook, Johanna

2013-05-01

Medication safety is a pressing concern for residential aged care facilities (RACFs). Retrospective studies in RACF settings identify inadequate communication between RACFs, doctors, hospitals and community pharmacies as the major cause of medication errors. Existing literature offers limited insight about the gaps in the existing information exchange process that may lead to medication errors. The aim of this research was to explicate the cognitive distribution that underlies RACF medication ordering and delivery to identify gaps in medication-related information exchange which lead to medication errors in RACFs. The study was undertaken in three RACFs in Sydney, Australia. Data were generated through ethnographic field work over a period of five months (May-September 2011). Triangulated analysis of data primarily focused on examining the transformation and exchange of information between different media across the process. The findings of this study highlight the extensive scope and intense nature of information exchange in RACF medication ordering and delivery. Rather than attributing error to individual care providers, the explication of distributed cognition processes enabled the identification of gaps in three information exchange dimensions which potentially contribute to the occurrence of medication errors namely: (1) design of medication charts which complicates order processing and record keeping (2) lack of coordination mechanisms between participants which results in misalignment of local practices (3) reliance on restricted communication bandwidth channels mainly telephone and fax which complicates the information processing requirements. The study demonstrates how the identification of these gaps enhances understanding of medication errors in RACFs. Application of the theoretical lens of distributed cognition can assist in enhancing our understanding of medication errors in RACFs through identification of gaps in information exchange. Understanding the dynamics of the cognitive process can inform the design of interventions to manage errors and improve residents' safety. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Defining quality metrics and improving safety and outcome in allergy care.

PubMed

Lee, Stella; Stachler, Robert J; Ferguson, Berrylin J

2014-04-01

The delivery of allergy immunotherapy in the otolaryngology office is variable and lacks standardization. Quality metrics encompasses the measurement of factors associated with good patient-centered care. These factors have yet to be defined in the delivery of allergy immunotherapy. We developed and applied quality metrics to 6 allergy practices affiliated with an academic otolaryngic allergy center. This work was conducted at a tertiary academic center providing care to over 1500 patients. We evaluated methods and variability between 6 sites. Tracking of errors and anaphylaxis was initiated across all sites. A nationwide survey of academic and private allergists was used to collect data on current practice and use of quality metrics. The most common types of errors recorded were patient identification errors (n = 4), followed by vial mixing errors (n = 3), and dosing errors (n = 2). There were 7 episodes of anaphylaxis of which 2 were secondary to dosing errors for a rate of 0.01% or 1 in every 10,000 injection visits/year. Site visits showed that 86% of key safety measures were followed. Analysis of nationwide survey responses revealed that quality metrics are still not well defined by either medical or otolaryngic allergy practices. Academic practices were statistically more likely to use quality metrics (p = 0.021) and perform systems reviews and audits in comparison to private practices (p = 0.005). Quality metrics in allergy delivery can help improve safety and quality care. These metrics need to be further defined by otolaryngic allergists in the changing health care environment. © 2014 ARS-AAOA, LLC.

[Risk Management: concepts and chances for public health].

PubMed

Palm, Stefan; Cardeneo, Margareta; Halber, Marco; Schrappe, Matthias

2002-01-15

Errors are a common problem in medicine and occur as a result of a complex process involving many contributing factors. Medical errors significantly reduce the safety margin for the patient and contribute additional costs in health care delivery. In most cases adverse events cannot be attributed to a single underlying cause. Therefore an effective risk management strategy must follow a system approach, which is based on counting and analysis of near misses. The development of defenses against the undesired effects of errors should be the main focus rather than asking the question "Who blundered?". Analysis of near misses (which in this context can be compared to indicators) offers several methodological advantages as compared to the analysis of errors and adverse events. Risk management is an integral element of quality management.

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study.

PubMed

Tariq, Amina; Georgiou, Andrew; Raban, Magdalena; Baysari, Melissa Therese; Westbrook, Johanna

2016-09-01

To identify system-related risk factors perceived to contribute to prescribing errors in Australian long-term care settings, that is, residential aged care facilities (RACFs). The study used qualitative methods to explore factors that contribute to unsafe prescribing in RACFs. Data were collected at three RACFs in metropolitan Sydney, Australia between May and November 2011. Participants included RACF managers, doctors, pharmacists and RACF staff actively involved in prescribing-related processes. Methods included non-participant observations (74 h), in-depth semistructured interviews (n=25) and artefact analysis. Detailed process activity models were developed for observed prescribing episodes supplemented by triangulated analysis using content analysis methods. System-related factors perceived to increase the risk of prescribing errors in RACFs were classified into three overarching themes: communication systems, team coordination and staff management. Factors associated with communication systems included limited point-of-care access to information, inadequate handovers, information storage across different media (paper, electronic and memory), poor legibility of charts, information double handling, multiple faxing of medication charts and reliance on manual chart reviews. Team factors included lack of established lines of responsibility, inadequate team communication and limited participation of doctors in multidisciplinary initiatives like medication advisory committee meetings. Factors related to staff management and workload included doctors' time constraints and their accessibility, lack of trained RACF staff and high RACF staff turnover. The study highlights several system-related factors including laborious methods for exchanging medication information, which often act together to contribute to prescribing errors. Multiple interventions (eg, technology systems, team communication protocols) are required to support the collaborative nature of RACF prescribing. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Reliability of clinical impact grading by healthcare professionals of common prescribing error and optimisation cases in critical care patients.

PubMed

Bourne, Richard S; Shulman, Rob; Tomlin, Mark; Borthwick, Mark; Berry, Will; Mills, Gary H

2017-04-01

To identify between and within profession-rater reliability of clinical impact grading for common critical care prescribing error and optimisation cases. To identify representative clinical impact grades for each individual case. Electronic questionnaire. 5 UK NHS Trusts. 30 Critical care healthcare professionals (doctors, pharmacists and nurses). Participants graded severity of clinical impact (5-point categorical scale) of 50 error and 55 optimisation cases. Case between and within profession-rater reliability and modal clinical impact grading. Between and within profession rater reliability analysis used linear mixed model and intraclass correlation, respectively. The majority of error and optimisation cases (both 76%) had a modal clinical severity grade of moderate or higher. Error cases: doctors graded clinical impact significantly lower than pharmacists (-0.25; P < 0.001) and nurses (-0.53; P < 0.001), with nurses significantly higher than pharmacists (0.28; P < 0.001). Optimisation cases: doctors graded clinical impact significantly lower than nurses and pharmacists (-0.39 and -0.5; P < 0.001, respectively). Within profession reliability grading was excellent for pharmacists (0.88 and 0.89; P < 0.001) and doctors (0.79 and 0.83; P < 0.001) but only fair to good for nurses (0.43 and 0.74; P < 0.001), for optimisation and error cases, respectively. Representative clinical impact grades for over 100 common prescribing error and optimisation cases are reported for potential clinical practice and research application. The between professional variability highlights the importance of multidisciplinary perspectives in assessment of medication error and optimisation cases in clinical practice and research. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

[Factors conditioning primary care services utilization. Empirical evidence and methodological inconsistencies].

PubMed

Sáez, M

2003-01-01

In Spain, the degree and characteristics of primary care services utilization have been the subject of analysis since at least the 1980s. One of the main reasons for this interest is to assess the extent to which utilization matches primary care needs. In fact, the provision of an adequate health service for those who most need it is a generally accepted priority. The evidence shows that individual characteristics, mainly health status, are the factors most closely related to primary care utilization. Other personal characteristics, such as gender and age, could act as modulators of health care need. Some family and/or cultural variables, as well as factors related to the health care professional and institutions, could explain some of the observed variability in primary care services utilization. Socioeconomic variables, such as income, reveal a paradox. From an aggregate perspective, income is the main determinant of utilization as well as of health care expenditure. When data are analyzed for individuals, however, income is not related to primary health utilization. The situation is controversial, with methodological implications and, above all, consequences for the assessment of the efficiency in primary care utilization. Review of the literature reveals certain methodological inconsistencies that could at least partly explain the disparity of the empirical results. Among others, the following flaws can be highlighted: design problems, measurement errors, misspecification, and misleading statistical methods.Some solutions, among others, are quasi-experiments, the use of large administrative databases and of primary data sources (design problems); differentiation between types of utilization and between units of analysis other than consultations, and correction of measurement errors in the explanatory variables (measurement errors); consideration of relevant explanatory variables (misspecification); and the use of multilevel models (statistical methods).

Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia.

PubMed

Samsiah, A; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi

2016-01-01

To explore and understand participants' perceptions and attitudes towards the reporting of medication errors (MEs). A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach. Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter's burden and benefit of reporting also were identified. Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use.

Speak Up: Help Prevent Errors in Your Care: Behavioral Health Care

MedlinePlus

... TM Help Prevent Errors in Your Care Behavioral Health Care To prevent health care errors, patients are urged to... SpeakUP TM Service ... individuals should be involved in their own behavioral health care. These efforts to increase consumer awareness and involvement ...

The Relationships Among Perceived Patients' Safety Culture, Intention to Report Errors, and Leader Coaching Behavior of Nurses in Korea: A Pilot Study.

PubMed

Ko, YuKyung; Yu, Soyoung

2017-09-01

This study was undertaken to explore the correlations among nurses' perceptions of patient safety culture, their intention to report errors, and leader coaching behaviors. The participants (N = 289) were nurses from 5 Korean hospitals with approximately 300 to 500 beds each. Sociodemographic variables, patient safety culture, intention to report errors, and coaching behavior were measured using self-report instruments. Data were analyzed using descriptive statistics, Pearson correlation coefficient, the t test, and the Mann-Whitney U test. Nurses' perceptions of patient safety culture and their intention to report errors showed significant differences between groups of nurses who rated their leaders as high-performing or low-performing coaches. Perceived coaching behavior showed a significant, positive correlation with patient safety culture and intention to report errors, i.e., as nurses' perceptions of coaching behaviors increased, so did their ratings of patient safety culture and error reporting. There is a need in health care settings for coaching by nurse managers to provide quality nursing care and thus improve patient safety. Programs that are systematically developed and implemented to enhance the coaching behaviors of nurse managers are crucial to the improvement of patient safety and nursing care. Moreover, a systematic analysis of the causes of malpractice, as opposed to a focus on the punitive consequences of errors, could increase error reporting and therefore promote a culture in which a higher level of patient safety can thrive.

Validating Domains of Patient Contextual Factors Essential to Preventing Contextual Errors: A Qualitative Study Conducted at Chicago Area Veterans Health Administration Sites.

PubMed

Binns-Calvey, Amy E; Malhiot, Alex; Kostovich, Carol T; LaVela, Sherri L; Stroupe, Kevin; Gerber, Ben S; Burkhart, Lisa; Weiner, Saul J; Weaver, Frances M

2017-09-01

"Patient context" indicates patient circumstances and characteristics or states that are essential to address when planning patient care. Specific patient "contextual factors," if overlooked, result in an inappropriate plan of care, a medical error termed a "contextual error." The myriad contextual factors that constitute patient context have been grouped into broad domains to create a taxonomy of challenges to consider when planning care. This study sought to validate a previously identified list of contextual domains. This qualitative study used directed content analysis. In 2014, 19 Department of Veterans Affairs (VA) providers (84% female) and 49 patients (86% male) from two VA medical centers and four outpatient clinics in the Chicago area participated in semistructured interviews and focus groups. Topics included patient-specific, community, and resource-related factors that affect patients' abilities to manage their care. Transcripts were analyzed with a previously identified list of contextual domains as a framework. Analysis of responses revealed that patients and providers identified the same 10 domains previously published, plus 3 additional ones. Based on comments made by patients and providers, the authors created a revised list of 12 domains from themes that emerged. Six pertain to patient circumstances such as access to care and financial situation, and 6 to patient characteristics/states including skills, abilities, and knowledge. Contextual factors in patients' lives may be essential to address for effective care planning. The rubric developed can serve as a "contextual differential" for clinicians to consider when addressing challenges patients face when planning their care.

The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care.

PubMed

Chedoe, Indra; Molendijk, Harry; Hospes, Wobbe; Van den Heuvel, Edwin R; Taxis, Katja

2012-11-01

To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU). Prospective study with a preintervention and postintervention measurement using direct observation. NICU in a tertiary hospital in the Netherlands. A multifaceted educational intervention including teaching and self-study. The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts. The incidence of errors decreased from 49% (43-54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25-36%). Preintervention, 0.3% (0-2%) medications contained severe errors, 26% (21-31%) moderate and 23% (18-28%) minor errors; postintervention, none 0% (0-2%) was severe, 23% (18-28%) moderate and 8% (5-12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29-0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)). The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.

CE: Nursing's Evolving Role in Patient Safety.

PubMed

Kowalski, Sonya L; Anthony, Maureen

2017-02-01

: Background: In its 1999 report To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM) suggested that between 44,000 and 98,000 Americans die annually as a result of medical errors. The report urged health care institutions to break the silence surrounding such errors and to implement changes that would promote a culture of safety. Our aim in conducting this content analysis of AJN articles was to explore the nurse's historical and contemporary role in promoting patient safety. We chose to focus on AJN because, as the oldest continuously published nursing journal, it provided a unique opportunity for us to view trends in nursing practice over more than 100 years. We reviewed all AJN tables of contents from 1900 through 2015, identifying for inclusion articles with titles that suggested a focus on nursing care, patient safety, or clinical content. We then read and analyzed each of the final 1,086 articles over a period of nine months. Our content analysis indicates that the early articles (from 1900 through 1920) focused on such safety measures as asepsis and the newly understood germ theory. In the 1930s, articles proposed methods for preventing medication errors and encouraged the development of written procedures to standardize care. During World War II, nurse authors identified improved patient survival rates with the use of "shock wards" and recovery rooms. The 1950s saw the emergence of progressive patient care initiatives, through which patients were assigned to various levels of care (intensive, intermediate, self, long-term, or home care) based on patient acuity. The 1960s brought increasingly complex equipment and medication regimens, which created safety problems. Hospital-acquired infections were recognized. Unit-dose medication was instituted in the 1970s. In the next two decades, medication and nursing-procedure safety were emphasized. From 2000 to 2015, articles looked beyond human performance as causes of health care errors to systemic factors, such as poor communication, patient-nurse ratios, provider skill mix, disruptive or inappropriate provider behavior, shift work, and long working hours. Emphasis on patient safety increased as patient care became more complex. As nurses developed a professional identity, they often put a spotlight on safety concerns and solutions. The IOM report, which encouraged research focused on systemic solutions to errors, was instrumental in furthering the very culture of safety that the nursing profession had championed.

An overview of intravenous-related medication administration errors as reported to MEDMARX, a national medication error-reporting program.

PubMed

Hicks, Rodney W; Becker, Shawn C

2006-01-01

Medication errors can be harmful, especially if they involve the intravenous (IV) route of administration. A mixed-methodology study using a 5-year review of 73,769 IV-related medication errors from a national medication error reporting program indicates that between 3% and 5% of these errors were harmful. The leading type of error was omission, and the leading cause of error involved clinician performance deficit. Using content analysis, three themes-product shortage, calculation errors, and tubing interconnectivity-emerge and appear to predispose patients to harm. Nurses often participate in IV therapy, and these findings have implications for practice and patient safety. Voluntary medication error-reporting programs afford an opportunity to improve patient care and to further understanding about the nature of IV-related medication errors.

Medical errors in primary care clinics – a cross sectional study

PubMed Central

2012-01-01

Background Patient safety is vital in patient care. There is a lack of studies on medical errors in primary care settings. The aim of the study is to determine the extent of diagnostic inaccuracies and management errors in public funded primary care clinics. Methods This was a cross-sectional study conducted in twelve public funded primary care clinics in Malaysia. A total of 1753 medical records were randomly selected in 12 primary care clinics in 2007 and were reviewed by trained family physicians for diagnostic, management and documentation errors, potential errors causing serious harm and likelihood of preventability of such errors. Results The majority of patient encounters (81%) were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0) of medical records and management errors in 53.2% (95% CI: 46.3, 60.2). For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4) of records, investigation errors in 21.7% (95% CI: 16.5, 26.8) and decision making errors in 14.5% (95% CI: 10.8, 18.2). A total of 39.9% (95% CI: 33.1, 46.7) of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1) of records. Nearly all errors (93.5%) detected were considered preventable. Conclusions The occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors. PMID:23267547

Opioid errors in inpatient palliative care services: a retrospective review.

PubMed

Heneka, Nicole; Shaw, Tim; Rowett, Debra; Lapkin, Samuel; Phillips, Jane L

2018-06-01

Opioids are a high-risk medicine frequently used to manage palliative patients' cancer-related pain and other symptoms. Despite the high volume of opioid use in inpatient palliative care services, and the potential for patient harm, few studies have focused on opioid errors in this population. To (i) identify the number of opioid errors reported by inpatient palliative care services, (ii) identify reported opioid error characteristics and (iii) determine the impact of opioid errors on palliative patient outcomes. A 24-month retrospective review of opioid errors reported in three inpatient palliative care services in one Australian state. Of the 55 opioid errors identified, 84% reached the patient. Most errors involved morphine (35%) or hydromorphone (29%). Opioid administration errors accounted for 76% of reported opioid errors, largely due to omitted dose (33%) or wrong dose (24%) errors. Patients were more likely to receive a lower dose of opioid than ordered as a direct result of an opioid error (57%), with errors adversely impacting pain and/or symptom management in 42% of patients. Half (53%) of the affected patients required additional treatment and/or care as a direct consequence of the opioid error. This retrospective review has provided valuable insights into the patterns and impact of opioid errors in inpatient palliative care services. Iatrogenic harm related to opioid underdosing errors contributed to palliative patients' unrelieved pain. Better understanding the factors that contribute to opioid errors and the role of safety culture in the palliative care service context warrants further investigation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units.

PubMed

Vogus, Timothy J; Sutcliffe, Kathleen M

2011-01-01

Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety. Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors. A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004. Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing. Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways. Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.

Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.

PubMed

McKaig, Donald; Collins, Christine; Elsaid, Khaled A

2014-09-01

A study was conducted to evaluate the impact of a reengineered approach to electronic error reporting at a 719-bed multidisciplinary urban medical center. The main outcome of interest was the monthly reported medication errors during the preimplementation (20 months) and postimplementation (26 months) phases. An interrupted time series analysis was used to describe baseline errors, immediate change following implementation of the current electronic error-reporting system (e-ERS), and trend of error reporting during postimplementation. Errors were categorized according to severity using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index classifications. Reported errors were further analyzed by reporter and error site. During preimplementation, the monthly reported errors mean was 40.0 (95% confidence interval [CI]: 36.3-43.7). Immediately following e-ERS implementation, monthly reported errors significantly increased by 19.4 errors (95% CI: 8.4-30.5). The change in slope of reported errors trend was estimated at 0.76 (95% CI: 0.07-1.22). Near misses and no-patient-harm errors accounted for 90% of all errors, while errors that caused increased patient monitoring or temporary harm accounted for 9% and 1%, respectively. Nurses were the most frequent reporters, while physicians were more likely to report high-severity errors. Medical care units accounted for approximately half of all reported errors. Following the intervention, there was a significant increase in reporting of prevented errors and errors that reached the patient with no resultant harm. This improvement in reporting was sustained for 26 months and has contributed to designing and implementing quality improvement initiatives to enhance the safety of the medication use process.

Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia

PubMed Central

Samsiah, A.; Othman, Noordin; Jamshed, Shazia; Hassali, Mohamed Azmi

2016-01-01

Objective To explore and understand participants’ perceptions and attitudes towards the reporting of medication errors (MEs). Methods A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach. Results Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter’s burden and benefit of reporting also were identified. Conclusions Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use. PMID:27906960

Impact of an electronic medication administration record on medication administration efficiency and errors.

PubMed

McComas, Jeffery; Riingen, Michelle; Chae Kim, Son

2014-12-01

The study aims were to evaluate the impact of electronic medication administration record implementation on medication administration efficiency and occurrence of medication errors as well as to identify the predictors of medication administration efficiency in an acute care setting. A prospective, observational study utilizing time-and-motion technique was conducted before and after electronic medication administration record implementation in November 2011. A total of 156 cases of medication administration activities (78 pre- and 78 post-electronic medication administration record) involving 38 nurses were observed at the point of care. A separate retrospective review of the hospital Midas+ medication error database was also performed to collect the rates and origin of medication errors for 6 months before and after electronic medication administration record implementation. The mean medication administration time actually increased from 11.3 to 14.4 minutes post-electronic medication administration record (P = .039). In a multivariate analysis, electronic medication administration record was not a predictor of medication administration time, but the distractions/interruptions during medication administration process were significant predictors. The mean hospital-wide medication errors significantly decreased from 11.0 to 5.3 events per month post-electronic medication administration record (P = .034). Although no improvement in medication administration efficiency was observed, electronic medication administration record improved the quality of care with a significant decrease in medication errors.

Biomass Thermogravimetric Analysis: Uncertainty Determination Methodology and Sampling Maps Generation

PubMed Central

Pazó, Jose A.; Granada, Enrique; Saavedra, Ángeles; Eguía, Pablo; Collazo, Joaquín

2010-01-01

The objective of this study was to develop a methodology for the determination of the maximum sampling error and confidence intervals of thermal properties obtained from thermogravimetric analysis (TG), including moisture, volatile matter, fixed carbon and ash content. The sampling procedure of the TG analysis was of particular interest and was conducted with care. The results of the present study were compared to those of a prompt analysis, and a correlation between the mean values and maximum sampling errors of the methods were not observed. In general, low and acceptable levels of uncertainty and error were obtained, demonstrating that the properties evaluated by TG analysis were representative of the overall fuel composition. The accurate determination of the thermal properties of biomass with precise confidence intervals is of particular interest in energetic biomass applications. PMID:20717532

The relationship between hand hygiene and health care-associated infection: it’s complicated

PubMed Central

McLaws, Mary-Louise

2015-01-01

The reasoning that improved hand hygiene compliance contributes to the prevention of health care-associated infections is widely accepted. It is also accepted that high hand hygiene alone cannot impact formidable risk factors, such as older age, immunosuppression, admission to the intensive care unit, longer length of stay, and indwelling devices. When hand hygiene interventions are concurrently undertaken with other routine or special preventive strategies, there is a potential for these concurrent strategies to confound the effect of the hand hygiene program. The result may be an overestimation of the hand hygiene intervention unless the design of the intervention or analysis controls the effect of the potential confounders. Other epidemiologic principles that may also impact the result of a hand hygiene program include failure to consider measurement error of the content of the hand hygiene program and the measurement error of compliance. Some epidemiological errors in hand hygiene programs aimed at reducing health care-associated infections are inherent and not easily controlled. Nevertheless, the inadvertent omission by authors to report these common epidemiological errors, including concurrent infection prevention strategies, suggests to readers that the effect of hand hygiene is greater than the sum of all infection prevention strategies. Worse still, this omission does not assist evidence-based practice. PMID:25678805

FMEA: a model for reducing medical errors.

PubMed

Chiozza, Maria Laura; Ponzetti, Clemente

2009-06-01

Patient safety is a management issue, in view of the fact that clinical risk management has become an important part of hospital management. Failure Mode and Effect Analysis (FMEA) is a proactive technique for error detection and reduction, firstly introduced within the aerospace industry in the 1960s. Early applications in the health care industry dating back to the 1990s included critical systems in the development and manufacture of drugs and in the prevention of medication errors in hospitals. In 2008, the Technical Committee of the International Organization for Standardization (ISO), licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. Here we describe the main steps of the FMEA process and review data available on the application of this technique to laboratory medicine. A significant reduction of the risk priority number (RPN) was obtained when applying FMEA to blood cross-matching, to clinical chemistry analytes, as well as to point-of-care testing (POCT).

Evaluation of drug administration errors in a teaching hospital

PubMed Central

2012-01-01

Background Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Methods Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects. Results Twenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors were detected (27.6%). There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501). The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%). The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission). In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC) and the number of patient under the nurse's care. Conclusion Medication administration errors are frequent. The identification of its determinants helps to undertake designed interventions. PMID:22409837

Evaluation of drug administration errors in a teaching hospital.

PubMed

Berdot, Sarah; Sabatier, Brigitte; Gillaizeau, Florence; Caruba, Thibaut; Prognon, Patrice; Durieux, Pierre

2012-03-12

Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Prospective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects. Twenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors were detected (27.6%). There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501). The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%). The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission). In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC) and the number of patient under the nurse's care. Medication administration errors are frequent. The identification of its determinants helps to undertake designed interventions.

Measuring quality in anatomic pathology.

PubMed

Raab, Stephen S; Grzybicki, Dana Marie

2008-06-01

This article focuses mainly on diagnostic accuracy in measuring quality in anatomic pathology, noting that measuring any quality metric is complex and demanding. The authors discuss standardization and its variability within and across areas of care delivery and efforts involving defining and measuring error to achieve pathology quality and patient safety. They propose that data linking error to patient outcome are critical for developing quality improvement initiatives targeting errors that cause patient harm in addition to using methods of root cause analysis, beyond those traditionally used in cytologic-histologic correlation, to assist in the development of error reduction and quality improvement plans.

Error in intensive care: psychological repercussions and defense mechanisms among health professionals.

PubMed

Laurent, Alexandra; Aubert, Laurence; Chahraoui, Khadija; Bioy, Antoine; Mariage, André; Quenot, Jean-Pierre; Capellier, Gilles

2014-11-01

To identify the psychological repercussions of an error on professionals in intensive care and to understand their evolution. To identify the psychological defense mechanisms used by professionals to cope with error. Qualitative study with clinical interviews. We transcribed recordings and analysed the data using an interpretative phenomenological analysis. Two ICUs in the teaching hospitals of Besançon and Dijon (France). Fourteen professionals in intensive care (20 physicians and 20 nurses). None. We conducted 40 individual semistructured interviews. The participants were invited to speak about the experience of error in ICU. The interviews were transcribed and analyzed thematically by three experts. In the month following the error, the professionals described feelings of guilt (53.8%) and shame (42.5%). These feelings were associated with anxiety states with rumination (37.5%) and fear for the patient (23%); a loss of confidence (32.5%); an inability to verbalize one's error (22.5%); questioning oneself at a professional level (20%); and anger toward the team (15%). In the long term, the error remains fixed in memory for many of the subjects (80%); on one hand, for 72.5%, it was associated with an increase in vigilance and verifications in their professional practice, and on the other hand, for three professionals, it was associated with a loss of confidence. Finally, three professionals felt guilt which still persisted at the time of the interview. We also observed different defense mechanisms implemented by the professional to fight against the emotional load inherent in the error: verbalization (70%), developing skills and knowledge (43%), rejecting responsibility (32.5%), and avoidance (23%). We also observed a minimization (60%) of the error during the interviews. It is important to take into account the psychological experience of error and the defense mechanisms developed following an error because they appear to determine the professional's capacity to acknowledge and disclose his/her error and to learn from it.

Physicians and pharmacists: collaboration to improve the quality of prescriptions in primary care in Mexico.

PubMed

Mino-León, Dolores; Reyes-Morales, Hortensia; Jasso, Luis; Douvoba, Svetlana Vladislavovna

2012-06-01

Inappropriate prescription is a relevant problem in primary health care settings in Mexico, with potentially harmful consequences for patients. To evaluate the effectiveness of incorporating a pharmacist into primary care health team to reduce prescription errors for patients with diabetes and/or hypertension. One Family Medicine Clinic from the Mexican Institute of Social Security in Mexico City. A "pharmacotherapy intervention" provided by pharmacists through a quasi experimental (before-after) design was carried out. Physicians who allowed access to their diabetes and/or hypertensive patients' medical records and prescriptions were included in the study. Prescription errors were classified as "filling", "clinical" or "both". Descriptive analysis, identification of potential drug-drug interactions (pD-DI), and comparison of the proportion of patients with prescriptions with errors detected "before" and "after" intervention were performed. Decrease in the proportion of patients who received prescriptions with errors after the intervention. Pharmacists detected at least one type of error in 79 out of 160 patients. Errors were "clinical", "both" and "filling" in 47, 21 and 11 of these patient's prescriptions respectively. Predominant errors were, in the subgroup of patient's prescriptions with "clinical" errors, pD-DI; in the subgroup of "both" errors, lack of information on dosing interval and pD-DI; and in the "filling" subgroup, lack of information on dosing interval. The pD-DI caused 50 % of the errors detected, from which 19 % were of major severity. The impact of the correction of errors post-intervention was observed in 19 % of patients who had erroneous prescriptions before the intervention of the pharmacist (49.3-30.3 %, p < 0.05). The impact of the intervention was relevant from a clinical point of view for the public health services in Mexico. The implementation of early warning systems of the most widely prescribed drugs is an alternative for reducing prescription errors and consequently the risks they may cause.

A Quantitative Analysis of the Effect of Simulation on Medication Administration in Nursing Students

ERIC Educational Resources Information Center

Scudmore, Casey

2013-01-01

Medication errors are a leading cause of injury and death in health care, and nurses are the last line of defense for patient safety. Nursing educators must develop curriculum to effectively teach nursing students to prevent medication errors and protect the public. The purpose of this quantitative, quasi-experimental study was to determine if…

Random measurement error: Why worry? An example of cardiovascular risk factors.

PubMed

Brakenhoff, Timo B; van Smeden, Maarten; Visseren, Frank L J; Groenwold, Rolf H H

2018-01-01

With the increased use of data not originally recorded for research, such as routine care data (or 'big data'), measurement error is bound to become an increasingly relevant problem in medical research. A common view among medical researchers on the influence of random measurement error (i.e. classical measurement error) is that its presence leads to some degree of systematic underestimation of studied exposure-outcome relations (i.e. attenuation of the effect estimate). For the common situation where the analysis involves at least one exposure and one confounder, we demonstrate that the direction of effect of random measurement error on the estimated exposure-outcome relations can be difficult to anticipate. Using three example studies on cardiovascular risk factors, we illustrate that random measurement error in the exposure and/or confounder can lead to underestimation as well as overestimation of exposure-outcome relations. We therefore advise medical researchers to refrain from making claims about the direction of effect of measurement error in their manuscripts, unless the appropriate inferential tools are used to study or alleviate the impact of measurement error from the analysis.

Clinical review: Medication errors in critical care

PubMed Central

Moyen, Eric; Camiré, Eric; Stelfox, Henry Thomas

2008-01-01

Medication errors in critical care are frequent, serious, and predictable. Critically ill patients are prescribed twice as many medications as patients outside of the intensive care unit (ICU) and nearly all will suffer a potentially life-threatening error at some point during their stay. The aim of this article is to provide a basic review of medication errors in the ICU, identify risk factors for medication errors, and suggest strategies to prevent errors and manage their consequences. PMID:18373883

Economic measurement of medical errors using a hospital claims database.

PubMed

David, Guy; Gunnarsson, Candace L; Waters, Heidi C; Horblyuk, Ruslan; Kaplan, Harold S

2013-01-01

The primary objective of this study was to estimate the occurrence and costs of medical errors from the hospital perspective. Methods from a recent actuarial study of medical errors were used to identify medical injuries. A visit qualified as an injury visit if at least 1 of 97 injury groupings occurred at that visit, and the percentage of injuries caused by medical error was estimated. Visits with more than four injuries were removed from the population to avoid overestimation of cost. Population estimates were extrapolated from the Premier hospital database to all US acute care hospitals. There were an estimated 161,655 medical errors in 2008 and 170,201 medical errors in 2009. Extrapolated to the entire US population, there were more than 4 million unique injury visits containing more than 1 million unique medical errors each year. This analysis estimated that the total annual cost of measurable medical errors in the United States was $985 million in 2008 and just over $1 billion in 2009. The median cost per error to hospitals was $892 for 2008 and rose to $939 in 2009. Nearly one third of all medical injuries were due to error in each year. Medical errors directly impact patient outcomes and hospitals' profitability, especially since 2008 when Medicare stopped reimbursing hospitals for care related to certain preventable medical errors. Hospitals must rigorously analyze causes of medical errors and implement comprehensive preventative programs to reduce their occurrence as the financial burden of medical errors shifts to hospitals. Copyright © 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

A prospective audit of a nurse independent prescribing within critical care.

PubMed

Carberry, Martin; Connelly, Sarah; Murphy, Jennifer

2013-05-01

To determine the prescribing activity of different staff groups within intensive care unit (ICU) and combined high dependency unit (HDU), namely trainee and consultant medical staff and advanced nurse practitioners in critical care (ANPCC); to determine the number and type of prescription errors; to compare error rates between prescribing groups and to raise awareness of prescribing activity within critical care. The introduction of government legislation has led to the development of non-medical prescribing roles in acute care. This has facilitated an opportunity for the ANPCC working in critical care to develop a prescribing role. The audit was performed over 7 days (Monday-Sunday), on rolling days over a 7-week period in September and October 2011 in three ICUs. All drug entries made on the ICU prescription by the three groups, trainee medical staff, ANPCCs and consultant anaesthetists, were audited once for errors. Data were collected by reviewing all drug entries for errors namely, patient data, drug dose, concentration, rate and frequency, legibility and prescriber signature. A paper data collection tool was used initially; data was later entered onto a Microsoft Access data base. A total of 1418 drug entries were audited from 77 patient prescription Cardexes. Error rates were reported as, 40 errors in 1418 prescriptions (2·8%): ANPCC errors, n = 2 in 388 prescriptions (0·6%); trainee medical staff errors, n = 33 in 984 (3·4%); consultant errors, n = 5 in 73 (6·8%). The error rates were significantly different for different prescribing groups (p < 0·01). This audit shows that prescribing error rates were low (2·8%). Having the lowest error rate, the nurse practitioners are at least as effective as other prescribing groups within this audit, in terms of errors only, in prescribing diligence. National data is required in order to benchmark independent nurse prescribing practice in critical care. These findings could be used to inform research and role development within the critical care. © 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses.

Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.

PubMed

Patel, Santosh; Loveridge, Robert

2015-12-01

Drug administration errors in obstetric neuraxial anesthesia can have devastating consequences. Although fully recognizing that they represent "only the tip of the iceberg," published case reports/series of these errors were reviewed in detail with the aim of estimating the frequency and the nature of these errors. We identified case reports and case series from MEDLINE and performed a quantitative analysis of the involved drugs, error setting, source of error, the observed complications, and any therapeutic interventions. We subsequently performed a qualitative analysis of the human factors involved and proposed modifications to practice. Twenty-nine cases were identified. Various drugs were given in error, but no direct effects on the course of labor, mode of delivery, or neonatal outcome were reported. Four maternal deaths from the accidental intrathecal administration of tranexamic acid were reported, all occurring after delivery of the fetus. A range of hemodynamic and neurologic signs and symptoms were noted, but the most commonly reported complication was the failure of the intended neuraxial anesthetic technique. Several human factors were present; most common factors were drug storage issues and similar drug appearance. Four practice recommendations were identified as being likely to have prevented the errors. The reported errors exposed latent conditions within health care systems. We suggest that the implementation of the following processes may decrease the risk of these types of drug errors: (1) Careful reading of the label on any drug ampule or syringe before the drug is drawn up or injected; (2) labeling all syringes; (3) checking labels with a second person or a device (such as a barcode reader linked to a computer) before the drug is drawn up or administered; and (4) use of non-Luer lock connectors on all epidural/spinal/combined spinal-epidural devices. Further study is required to determine whether routine use of these processes will reduce drug error.

[Adverse events in general surgery. A prospective analysis of 13,950 consecutive patients].

PubMed

Rebasa, Pere; Mora, Laura; Vallverdú, Helena; Luna, Alexis; Montmany, Sandra; Romaguera, Andreu; Navarro, Salvador

2011-11-01

Adverse event (AE) rates in General Surgery vary, according to different authors and recording methods, between 2% and 30%. Six years ago we designed a prospective AE recording system to change patient safety culture in our Department. We present the results of this work after a 6 year follow-up. The AE, sequelae and health care errors in a University Hospital surgery department were recorded. An analysis of each incident recorded was performed by a reviewer. The data was entered into data base for rapid access and consultation. The results were routinely presented in Departmental morbidity-mortality sessions. A total of 13,950 patients had suffered 11,254 AE, which affected 5142 of them (36.9% of admissions). A total of 920 patients were subjected to at least one health care error (6.6% of admissions). This meant that 6.6% of our patients suffered an avoidable AE. The overall mortality at 5 years in our department was 2.72% (380 deaths). An adverse event was implicated in the death of the patient in 180 cases (1.29% of admissions). In 49 cases (0.35% of admissions), mortality could be attributed to an avoidable AE. After 6 years there tends to be an increasingly lower incidence of errors. The exhaustive and prospective recording of AE leads to changes in patient safety culture in a Surgery Department and helps decrease the incidence of health care errors. Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved.

Preventing medical errors by designing benign failures.

PubMed

Grout, John R

2003-07-01

One way to successfully reduce medical errors is to design health care systems that are more resistant to the tendencies of human beings to err. One interdisciplinary approach entails creating design changes, mitigating human errors, and making human error irrelevant to outcomes. This approach is intended to facilitate the creation of benign failures, which have been called mistake-proofing devices and forcing functions elsewhere. USING FAULT TREES TO DESIGN FORCING FUNCTIONS: A fault tree is a graphical tool used to understand the relationships that either directly cause or contribute to the cause of a particular failure. A careful analysis of a fault tree enables the analyst to anticipate how the process will behave after the change. EXAMPLE OF AN APPLICATION: A scenario in which a patient is scalded while bathing can serve as an example of how multiple fault trees can be used to design forcing functions. The first fault tree shows the undesirable event--patient scalded while bathing. The second fault tree has a benign event--no water. Adding a scald valve changes the outcome from the undesirable event ("patient scalded while bathing") to the benign event ("no water") Analysis of fault trees does not ensure or guarantee that changes necessary to eliminate error actually occur. Most mistake-proofing is used to prevent simple errors and to create well-defended processes, but complex errors can also result. The utilization of mistake-proofing or forcing functions can be thought of as changing the logic of a process. Errors that formerly caused undesirable failures can be converted into the causes of benign failures. The use of fault trees can provide a variety of insights into the design of forcing functions that will improve patient safety.

Are health care provider organizations ready to tackle diagnostic error? A survey of Leapfrog-participating hospitals.

PubMed

Newman-Toker, David E; Austin, J Matthew; Derk, Jordan; Danforth, Melissa; Graber, Mark L

2017-06-27

A 2015 National Academy of Medicine report on improving diagnosis in health care made recommendations for direct action by hospitals and health systems. Little is known about how health care provider organizations are addressing diagnostic safety/quality. This study is an anonymous online survey of safety professionals from US hospitals and health systems in July-August 2016. The survey was sent to those attending a Leapfrog Group webinar on misdiagnosis (n=188). The instrument was focused on knowledge, attitudes, and capability to address diagnostic errors at the institutional level. Overall, 61 (32%) responded, including community hospitals (42%), integrated health networks (25%), and academic centers (21%). Awareness was high, but commitment and capability were low (31% of leaders understand the problem; 28% have sufficient safety resources; and 25% have made diagnosis a top institutional safety priority). Ongoing efforts to improve diagnostic safety were sparse and mostly included root cause analysis and peer review feedback around diagnostic errors. The top three barriers to addressing diagnostic error were lack of awareness of the problem, lack of measures of diagnostic accuracy and error, and lack of feedback on diagnostic performance. The top two tools viewed as critically important for locally tackling the problem were routine feedback on diagnostic performance and culture change to emphasize diagnostic safety. Although hospitals and health systems appear to be aware of diagnostic errors as a major safety imperative, most organizations (even those that appear to be making a strong commitment to patient safety) are not yet doing much to improve diagnosis. Going forward, efforts to activate health care organizations will be essential to improving diagnostic safety.

Heterogenic Solid Biofuel Sampling Methodology and Uncertainty Associated with Prompt Analysis

PubMed Central

Pazó, Jose A.; Granada, Enrique; Saavedra, Ángeles; Patiño, David; Collazo, Joaquín

2010-01-01

Accurate determination of the properties of biomass is of particular interest in studies on biomass combustion or cofiring. The aim of this paper is to develop a methodology for prompt analysis of heterogeneous solid fuels with an acceptable degree of accuracy. Special care must be taken with the sampling procedure to achieve an acceptable degree of error and low statistical uncertainty. A sampling and error determination methodology for prompt analysis is presented and validated. Two approaches for the propagation of errors are also given and some comparisons are made in order to determine which may be better in this context. Results show in general low, acceptable levels of uncertainty, demonstrating that the samples obtained in the process are representative of the overall fuel composition. PMID:20559506

The influence of the structure and culture of medical group practices on prescription drug errors.

PubMed

Kralewski, John E; Dowd, Bryan E; Heaton, Alan; Kaissi, Amer

2005-08-01

This project was designed to identify the magnitude of prescription drug errors in medical group practices and to explore the influence of the practice structure and culture on those error rates. Seventy-eight practices serving an upper Midwest managed care (Care Plus) plan during 2001 were included in the study. Using Care Plus claims data, prescription drug error rates were calculated at the enrollee level and then were aggregated to the group practice that each enrollee selected to provide and manage their care. Practice structure and culture data were obtained from surveys of the practices. Data were analyzed using multivariate regression. Both the culture and the structure of these group practices appear to influence prescription drug error rates. Seeing more patients per clinic hour, more prescriptions per patient, and being cared for in a rural clinic were all strongly associated with more errors. Conversely, having a case manager program is strongly related to fewer errors in all of our analyses. The culture of the practices clearly influences error rates, but the findings are mixed. Practices with cohesive cultures have lower error rates but, contrary to our hypothesis, cultures that value physician autonomy and individuality also have lower error rates than those with a more organizational orientation. Our study supports the contention that there are a substantial number of prescription drug errors in the ambulatory care sector. Even by the strictest definition, there were about 13 errors per 100 prescriptions for Care Plus patients in these group practices during 2001. Our study demonstrates that the structure of medical group practices influences prescription drug error rates. In some cases, this appears to be a direct relationship, such as the effects of having a case manager program on fewer drug errors, but in other cases the effect appears to be indirect through the improvement of drug prescribing practices. An important aspect of this study is that it provides insights into the relationships of the structure and culture of medical group practices and prescription drug errors and provides direction for future research. Research focused on the factors influencing the high error rates in rural areas and how the interaction of practice structural and cultural attributes influence error rates would add important insights into our findings. For medical practice directors, our data show that they should focus on patient care coordination to reduce errors.

Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: A systematic review.

PubMed

Heneka, Nicole; Shaw, Tim; Rowett, Debra; Phillips, Jane L

2016-06-01

Opioids are the primary pharmacological treatment for cancer pain and, in the palliative care setting, are routinely used to manage symptoms at the end of life. Opioids are one of the most frequently reported drug classes in medication errors causing patient harm. Despite their widespread use, little is known about the incidence and impact of opioid medication errors in oncology and palliative care settings. To determine the incidence, types and impact of reported opioid medication errors in adult oncology and palliative care patient settings. A systematic review. Five electronic databases and the grey literature were searched from 1980 to August 2014. Empirical studies published in English, reporting data on opioid medication error incidence, types or patient impact, within adult oncology and/or palliative care services, were included. Popay's narrative synthesis approach was used to analyse data. Five empirical studies were included in this review. Opioid error incidence rate was difficult to ascertain as each study focussed on a single narrow area of error. The predominant error type related to deviation from opioid prescribing guidelines, such as incorrect dosing intervals. None of the included studies reported the degree of patient harm resulting from opioid errors. This review has highlighted the paucity of the literature examining opioid error incidence, types and patient impact in adult oncology and palliative care settings. Defining, identifying and quantifying error reporting practices for these populations should be an essential component of future oncology and palliative care quality and safety initiatives. © The Author(s) 2015.

Medication Timing Errors for Parkinson's Disease: Perspectives Held by Caregivers and People with Parkinson's in New Zealand

PubMed Central

Buetow, Stephen; Henshaw, Jenny; Bryant, Linda; O'Sullivan, Deirdre

2010-01-01

Background. Common but seldom published are Parkinson's disease (PD) medication errors involving late, extra, or missed doses. These errors can reduce medication effectiveness and the quality of life of people with PD and their caregivers. Objective. To explore lay perspectives of factors contributing to medication timing errors for PD in hospital and community settings. Design and Methods. This qualitative research purposively sampled individuals with PD, or a proxy of their choice, throughout New Zealand during 2008-2009. Data collection involved 20 semistructured, personal interviews by telephone. A general inductive analysis of the data identified core insights consistent with the study objective. Results. Five themes help to account for possible timing adherence errors by people with PD, their caregivers or professionals. The themes are the abrupt withdrawal of PD medication; wrong, vague or misread instructions; devaluation of the lay role in managing PD medications; deficits in professional knowledge and in caring behavior around PD in formal health care settings; and lay forgetfulness. Conclusions. The results add to the limited published research on medication errors in PD and help to confirm anecdotal experience internationally. They indicate opportunities for professionals and lay people to work together to reduce errors in the timing of medication for PD in hospital and community settings. PMID:20975777

Use of error grid analysis to evaluate acceptability of a point of care prothrombin time meter.

PubMed

Petersen, John R; Vonmarensdorf, Hans M; Weiss, Heidi L; Elghetany, M Tarek

2010-02-01

Statistical methods (linear regression, correlation analysis, etc.) are frequently employed in comparing methods in the central laboratory (CL). Assessing acceptability of point of care testing (POCT) equipment, however, is more difficult because statistically significant biases may not have an impact on clinical care. We showed how error grid (EG) analysis can be used to evaluate POCT PT INR with the CL. We compared results from 103 patients seen in an anti-coagulation clinic that were on Coumadin maintenance therapy using fingerstick samples for POCT (Roche CoaguChek XS and S) and citrated venous blood samples for CL (Stago STAR). To compare clinical acceptability of results we developed an EG with zones A, B, C and D. Using 2nd order polynomial equation analysis, POCT results highly correlate with the CL for CoaguChek XS (R(2)=0. 955) and CoaguChek S (R(2)=0. 93), respectively but does not indicate if POCT results are clinically interchangeable with the CL. Using EG it is readily apparent which levels can be considered clinically identical to the CL despite analytical bias. We have demonstrated the usefulness of EG in determining acceptability of POCT PT INR testing and how it can be used to determine cut-offs where differences in POCT results may impact clinical care. Copyright 2009 Elsevier B.V. All rights reserved.

Prevention of medication errors: detection and audit.

PubMed

Montesi, Germana; Lechi, Alessandro

2009-06-01

1. Medication errors have important implications for patient safety, and their identification is a main target in improving clinical practice errors, in order to prevent adverse events. 2. Error detection is the first crucial step. Approaches to this are likely to be different in research and routine care, and the most suitable must be chosen according to the setting. 3. The major methods for detecting medication errors and associated adverse drug-related events are chart review, computerized monitoring, administrative databases, and claims data, using direct observation, incident reporting, and patient monitoring. All of these methods have both advantages and limitations. 4. Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of a culture of safe practice. Combining and comparing data from various and encourages the diffusion of a culture of safe practice sources increases the reliability of the system. 5. Error prevention can be planned by means of retroactive and proactive tools, such as audit and Failure Mode, Effect, and Criticality Analysis (FMECA). Audit is also an educational activity, which promotes high-quality care; it should be carried out regularly. In an audit cycle we can compare what is actually done against reference standards and put in place corrective actions to improve the performances of individuals and systems. 6. Patient safety must be the first aim in every setting, in order to build safer systems, learning from errors and reducing the human and fiscal costs.

Threat and error management for anesthesiologists: a predictive risk taxonomy

PubMed Central

Ruskin, Keith J.; Stiegler, Marjorie P.; Park, Kellie; Guffey, Patrick; Kurup, Viji; Chidester, Thomas

2015-01-01

Purpose of review Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care. Recent findings Threat and error management (TEM) describes adverse events in terms of risks or challenges that are present in an operational environment (threats) and the actions of specific personnel that potentiate or exacerbate those threats (errors). TEM is a technique widely used in aviation, and can be adapted for the use in a medical setting to predict high-risk situations and prevent errors in the perioperative period. A threat taxonomy is a novel way of classifying and predicting the hazards that can occur in the operating room. TEM can be used to identify error-producing situations, analyze adverse events, and design training scenarios. Summary TEM offers a multifaceted strategy for identifying hazards, reducing errors, and training physicians. A threat taxonomy may improve analysis of critical events with subsequent development of specific interventions, and may also serve as a framework for training programs in risk mitigation. PMID:24113268

Quality: performance improvement, teamwork, information technology and protocols.

PubMed

Coleman, Nana E; Pon, Steven

2013-04-01

Using the Institute of Medicine framework that outlines the domains of quality, this article considers four key aspects of health care delivery which have the potential to significantly affect the quality of health care within the pediatric intensive care unit. The discussion covers: performance improvement and how existing methods for reporting, review, and analysis of medical error relate to patient care; team composition and workflow; and the impact of information technologies on clinical practice. Also considered is how protocol-driven and standardized practice affects both patients and the fiscal interests of the health care system.

[Errors in laboratory daily practice].

PubMed

Larrose, C; Le Carrer, D

2007-01-01

Legislation set by GBEA (Guide de bonne exécution des analyses) requires that, before performing analysis, the laboratory directors have to check both the nature of the samples and the patients identity. The data processing of requisition forms, which identifies key errors, was established in 2000 and in 2002 by the specialized biochemistry laboratory, also with the contribution of the reception centre for biological samples. The laboratories follow a strict criteria of defining acceptability as a starting point for the reception to then check requisition forms and biological samples. All errors are logged into the laboratory database and analysis report are sent to the care unit specifying the problems and the consequences they have on the analysis. The data is then assessed by the laboratory directors to produce monthly or annual statistical reports. This indicates the number of errors, which are then indexed to patient files to reveal the specific problem areas, therefore allowing the laboratory directors to teach the nurses and enable corrective action.

Patient Safety Culture in Intensive Care Units from the Perspective of Nurses: A Cross-Sectional Study.

PubMed

Farzi, Sedigheh; Moladoost, Azam; Bahrami, Masoud; Farzi, Saba; Etminani, Reza

2017-01-01

One of the goals of nursing is providing safe care, prevention of injury, and health promotion of patients. Patient safety in intensive care units is threatened for various reasons. This study aimed to survey patient safety culture from the perspective of nurses in intensive care units. This cross-sectional study was conducted in 2016. Sampling was done using the convenience method. The sample consisted of 367 nurses working in intensive care units of teaching hospitals affiliated to Isfahan University of Medical Sciences. Data collection was performed using a two-part questionnaire that included demographic and hospital survey on Patient Safety Culture (HSOPSC) questionnaire. Data analysis was done using descriptive statistics (mean and standard deviation). Among the 12 dimensions of safety culture, the nurses assigned the highest score to "team work within units" (97.3%) and "Organizational learning-continuous improvement" (84%). They assigned the least score to "handoffs and transitions"(21.1%), "non-punitive response to errors" (24.7%), "Staffing" (35.6%), "Communication openness" (47.5%), and "Teamwork across units" (49.4%). The patient safety culture dimensions have low levels that require adequate attention and essential measures of health care centers including facilitating teamwork, providing adequate staff, and developing a checklist of handoffs and transitions. Furthermore, to increase reporting error and to promote a patient safety culture in intensive care units, some strategies should be adopted including a system-based approach to deal with the error.

Automatic variance analysis of multistage care pathways.

PubMed

Li, Xiang; Liu, Haifeng; Zhang, Shilei; Mei, Jing; Xie, Guotong; Yu, Yiqin; Li, Jing; Lakshmanan, Geetika T

2014-01-01

A care pathway (CP) is a standardized process that consists of multiple care stages, clinical activities and their relations, aimed at ensuring and enhancing the quality of care. However, actual care may deviate from the planned CP, and analysis of these deviations can help clinicians refine the CP and reduce medical errors. In this paper, we propose a CP variance analysis method to automatically identify the deviations between actual patient traces in electronic medical records (EMR) and a multistage CP. As the care stage information is usually unavailable in EMR, we first align every trace with the CP using a hidden Markov model. From the aligned traces, we report three types of deviations for every care stage: additional activities, absent activities and violated constraints, which are identified by using the techniques of temporal logic and binomial tests. The method has been applied to a CP for the management of congestive heart failure and real world EMR, providing meaningful evidence for the further improvement of care quality.

Implementing parallel spreadsheet models for health policy decisions: The impact of unintentional errors on model projections

PubMed Central

Bailey, Stephanie L.; Bono, Rose S.; Nash, Denis; Kimmel, April D.

2018-01-01

Background Spreadsheet software is increasingly used to implement systems science models informing health policy decisions, both in academia and in practice where technical capacity may be limited. However, spreadsheet models are prone to unintentional errors that may not always be identified using standard error-checking techniques. Our objective was to illustrate, through a methodologic case study analysis, the impact of unintentional errors on model projections by implementing parallel model versions. Methods We leveraged a real-world need to revise an existing spreadsheet model designed to inform HIV policy. We developed three parallel versions of a previously validated spreadsheet-based model; versions differed by the spreadsheet cell-referencing approach (named single cells; column/row references; named matrices). For each version, we implemented three model revisions (re-entry into care; guideline-concordant treatment initiation; immediate treatment initiation). After standard error-checking, we identified unintentional errors by comparing model output across the three versions. Concordant model output across all versions was considered error-free. We calculated the impact of unintentional errors as the percentage difference in model projections between model versions with and without unintentional errors, using +/-5% difference to define a material error. Results We identified 58 original and 4,331 propagated unintentional errors across all model versions and revisions. Over 40% (24/58) of original unintentional errors occurred in the column/row reference model version; most (23/24) were due to incorrect cell references. Overall, >20% of model spreadsheet cells had material unintentional errors. When examining error impact along the HIV care continuum, the percentage difference between versions with and without unintentional errors ranged from +3% to +16% (named single cells), +26% to +76% (column/row reference), and 0% (named matrices). Conclusions Standard error-checking techniques may not identify all errors in spreadsheet-based models. Comparing parallel model versions can aid in identifying unintentional errors and promoting reliable model projections, particularly when resources are limited. PMID:29570737

Implementing parallel spreadsheet models for health policy decisions: The impact of unintentional errors on model projections.

PubMed

Bailey, Stephanie L; Bono, Rose S; Nash, Denis; Kimmel, April D

2018-01-01

Spreadsheet software is increasingly used to implement systems science models informing health policy decisions, both in academia and in practice where technical capacity may be limited. However, spreadsheet models are prone to unintentional errors that may not always be identified using standard error-checking techniques. Our objective was to illustrate, through a methodologic case study analysis, the impact of unintentional errors on model projections by implementing parallel model versions. We leveraged a real-world need to revise an existing spreadsheet model designed to inform HIV policy. We developed three parallel versions of a previously validated spreadsheet-based model; versions differed by the spreadsheet cell-referencing approach (named single cells; column/row references; named matrices). For each version, we implemented three model revisions (re-entry into care; guideline-concordant treatment initiation; immediate treatment initiation). After standard error-checking, we identified unintentional errors by comparing model output across the three versions. Concordant model output across all versions was considered error-free. We calculated the impact of unintentional errors as the percentage difference in model projections between model versions with and without unintentional errors, using +/-5% difference to define a material error. We identified 58 original and 4,331 propagated unintentional errors across all model versions and revisions. Over 40% (24/58) of original unintentional errors occurred in the column/row reference model version; most (23/24) were due to incorrect cell references. Overall, >20% of model spreadsheet cells had material unintentional errors. When examining error impact along the HIV care continuum, the percentage difference between versions with and without unintentional errors ranged from +3% to +16% (named single cells), +26% to +76% (column/row reference), and 0% (named matrices). Standard error-checking techniques may not identify all errors in spreadsheet-based models. Comparing parallel model versions can aid in identifying unintentional errors and promoting reliable model projections, particularly when resources are limited.

Reducing medication errors in critical care: a multimodal approach

PubMed Central

Kruer, Rachel M; Jarrell, Andrew S; Latif, Asad

2014-01-01

The Institute of Medicine has reported that medication errors are the single most common type of error in health care, representing 19% of all adverse events, while accounting for over 7,000 deaths annually. The frequency of medication errors in adult intensive care units can be as high as 947 per 1,000 patient-days, with a median of 105.9 per 1,000 patient-days. The formulation of drugs is a potential contributor to medication errors. Challenges related to drug formulation are specific to the various routes of medication administration, though errors associated with medication appearance and labeling occur among all drug formulations and routes of administration. Addressing these multifaceted challenges requires a multimodal approach. Changes in technology, training, systems, and safety culture are all strategies to potentially reduce medication errors related to drug formulation in the intensive care unit. PMID:25210478

Cause-and-effect mapping of critical events.

PubMed

Graves, Krisanne; Simmons, Debora; Galley, Mark D

2010-06-01

Health care errors are routinely reported in the scientific and public press and have become a major concern for most Americans. In learning to identify and analyze errors health care can develop some of the skills of a learning organization, including the concept of systems thinking. Modern experts in improving quality have been working in other high-risk industries since the 1920s making structured organizational changes through various frameworks for quality methods including continuous quality improvement and total quality management. When using these tools, it is important to understand systems thinking and the concept of processes within organization. Within these frameworks of improvement, several tools can be used in the analysis of errors. This article introduces a robust tool with a broad analytical view consistent with systems thinking, called CauseMapping (ThinkReliability, Houston, TX, USA), which can be used to systematically analyze the process and the problem at the same time. Copyright 2010 Elsevier Inc. All rights reserved.

Model selection for marginal regression analysis of longitudinal data with missing observations and covariate measurement error.

PubMed

Shen, Chung-Wei; Chen, Yi-Hau

2015-10-01

Missing observations and covariate measurement error commonly arise in longitudinal data. However, existing methods for model selection in marginal regression analysis of longitudinal data fail to address the potential bias resulting from these issues. To tackle this problem, we propose a new model selection criterion, the Generalized Longitudinal Information Criterion, which is based on an approximately unbiased estimator for the expected quadratic error of a considered marginal model accounting for both data missingness and covariate measurement error. The simulation results reveal that the proposed method performs quite well in the presence of missing data and covariate measurement error. On the contrary, the naive procedures without taking care of such complexity in data may perform quite poorly. The proposed method is applied to data from the Taiwan Longitudinal Study on Aging to assess the relationship of depression with health and social status in the elderly, accommodating measurement error in the covariate as well as missing observations. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

The "Measuring Outcomes of Clinical Connectivity" (MOCC) trial: investigating data entry errors in the Electronic Primary Care Research Network (ePCRN).

PubMed

Fontaine, Patricia; Mendenhall, Tai J; Peterson, Kevin; Speedie, Stuart M

2007-01-01

The electronic Primary Care Research Network (ePCRN) enrolled PBRN researchers in a feasibility trial to test the functionality of the network's electronic architecture and investigate error rates associated with two data entry strategies used in clinical trials. PBRN physicians and research assistants who registered with the ePCRN were eligible to participate. After online consent and randomization, participants viewed simulated patient records, presented as either abstracted data (short form) or progress notes (long form). Participants transcribed 50 data elements onto electronic case report forms (CRFs) without integrated field restrictions. Data errors were analyzed. Ten geographically dispersed PBRNs enrolled 100 members and completed the study in less than 7 weeks. The estimated overall error rate if field restrictions had been applied was 2.3%. Participants entering data from the short form had a higher rate of correctly entered data fields (94.5% vs 90.8%, P = .004) and significantly more error-free records (P = .003). Feasibility outcomes integral to completion of an Internet-based, multisite study were successfully achieved. Further development of programmable electronic safeguards is indicated. The error analysis conducted in this study will aid design of specific field restrictions for electronic CRFs, an important component of clinical trial management systems.

Self-reported medical, medication and laboratory error in eight countries: risk factors for chronically ill adults.

PubMed

Scobie, Andrea

2011-04-01

To identify risk factors associated with self-reported medical, medication and laboratory error in eight countries. The Commonwealth Fund's 2008 International Health Policy Survey of chronically ill patients in eight countries. None. A multi-country telephone survey was conducted between 3 March and 30 May 2008 with patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK and the USA who self-reported being chronically ill. A bivariate analysis was performed to determine significant explanatory variables of medical, medication and laboratory error (P < 0.01) for inclusion in a binary logistic regression model. The final regression model included eight risk factors for self-reported error: age 65 and under, education level of some college or less, presence of two or more chronic conditions, high prescription drug use (four+ drugs), four or more doctors seen within 2 years, a care coordination problem, poor doctor-patient communication and use of an emergency department. Risk factors with the greatest ability to predict experiencing an error encompassed issues with coordination of care and provider knowledge of a patient's medical history. The identification of these risk factors could help policymakers and organizations to proactively reduce the likelihood of error through greater examination of system- and organization-level practices.

Time trend of injection drug errors before and after implementation of bar-code verification system.

PubMed

Sakushima, Ken; Umeki, Reona; Endoh, Akira; Ito, Yoichi M; Nasuhara, Yasuyuki

2015-01-01

Bar-code technology, used for verification of patients and their medication, could prevent medication errors in clinical practice. Retrospective analysis of electronically stored medical error reports was conducted in a university hospital. The number of reported medication errors of injected drugs, including wrong drug administration and administration to the wrong patient, was compared before and after implementation of the bar-code verification system for inpatient care. A total of 2867 error reports associated with injection drugs were extracted. Wrong patient errors decreased significantly after implementation of the bar-code verification system (17.4/year vs. 4.5/year, p< 0.05), although wrong drug errors did not decrease sufficiently (24.2/year vs. 20.3/year). The source of medication errors due to wrong drugs was drug preparation in hospital wards. Bar-code medication administration is effective for prevention of wrong patient errors. However, ordinary bar-code verification systems are limited in their ability to prevent incorrect drug preparation in hospital wards.

Effects of Programmed Teaching Errors on Acquisition and Durability of Self-Care Skills

ERIC Educational Resources Information Center

Donnelly, Maeve G.; Karsten, Amanda M.

2017-01-01

This investigation sheds light on necessary and sufficient conditions to establish self-care behavior chains among people with developmental disabilities. First, a descriptive assessment (DA) identified the types of teaching errors that occurred during self-care instruction. Second, the relative effects of three teaching errors observed during the…

Ten years of preanalytical monitoring and control: Synthetic Balanced Score Card Indicator

PubMed Central

López-Garrigós, Maite; Flores, Emilio; Santo-Quiles, Ana; Gutierrez, Mercedes; Lugo, Javier; Lillo, Rosa; Leiva-Salinas, Carlos

2015-01-01

Introduction Preanalytical control and monitoring continue to be an important issue for clinical laboratory professionals. The aim of the study was to evaluate a monitoring system of preanalytical errors regarding not suitable samples for analysis, based on different indicators; to compare such indicators in different phlebotomy centres; and finally to evaluate a single synthetic preanalytical indicator that may be included in the balanced scorecard management system (BSC). Materials and methods We collected individual and global preanalytical errors in haematology, coagulation, chemistry, and urine samples analysis. We also analyzed a synthetic indicator that represents the sum of all types of preanalytical errors, expressed in a sigma level. We studied the evolution of those indicators over time and compared indicator results by way of the comparison of proportions and Chi-square. Results There was a decrease in the number of errors along the years (P < 0.001). This pattern was confirmed in primary care patients, inpatients and outpatients. In blood samples, fewer errors occurred in outpatients, followed by inpatients. Conclusion We present a practical and effective methodology to monitor unsuitable sample preanalytical errors. The synthetic indicator results summarize overall preanalytical sample errors, and can be used as part of BSC management system. PMID:25672466

Considerations for analysis of time-to-event outcomes measured with error: Bias and correction with SIMEX.

PubMed

Oh, Eric J; Shepherd, Bryan E; Lumley, Thomas; Shaw, Pamela A

2018-04-15

For time-to-event outcomes, a rich literature exists on the bias introduced by covariate measurement error in regression models, such as the Cox model, and methods of analysis to address this bias. By comparison, less attention has been given to understanding the impact or addressing errors in the failure time outcome. For many diseases, the timing of an event of interest (such as progression-free survival or time to AIDS progression) can be difficult to assess or reliant on self-report and therefore prone to measurement error. For linear models, it is well known that random errors in the outcome variable do not bias regression estimates. With nonlinear models, however, even random error or misclassification can introduce bias into estimated parameters. We compare the performance of 2 common regression models, the Cox and Weibull models, in the setting of measurement error in the failure time outcome. We introduce an extension of the SIMEX method to correct for bias in hazard ratio estimates from the Cox model and discuss other analysis options to address measurement error in the response. A formula to estimate the bias induced into the hazard ratio by classical measurement error in the event time for a log-linear survival model is presented. Detailed numerical studies are presented to examine the performance of the proposed SIMEX method under varying levels and parametric forms of the error in the outcome. We further illustrate the method with observational data on HIV outcomes from the Vanderbilt Comprehensive Care Clinic. Copyright © 2017 John Wiley & Sons, Ltd.

Hospital staff registered nurses' perception of horizontal violence, peer relationships, and the quality and safety of patient care.

PubMed

Purpora, Christina; Blegen, Mary A; Stotts, Nancy A

2015-01-01

To test hypotheses from a horizontal violence and quality and safety of patient care model: horizontal violence (negative behavior among peers) is inversely related to peer relations, quality of care and it is positively related to errors and adverse events. Additionally, the association between horizontal violence, peer relations, quality of care, errors and adverse events, and nurse and work characteristics were determined. A random sample (n= 175) of hospital staff Registered Nurses working in California. Nurses participated via survey. Bivariate and multivariate analyses tested the study hypotheses. Hypotheses were supported. Horizontal violence was inversely related to peer relations and quality of care, and positively related to errors and adverse events. Including peer relations in the analyses altered the relationship between horizontal violence and quality of care but not between horizontal violence, errors and adverse events. Nurse and hospital characteristics were not related to other variables. Clinical area contributed significantly in predicting the quality of care, errors and adverse events but not peer relationships. Horizontal violence affects peer relationships and the quality and safety of patient care as perceived by participating nurses. Supportive peer relationships are important to mitigate the impact of horizontal violence on quality of care.

Obligation towards medical errors disclosure at a tertiary care hospital in Dubai, UAE

PubMed Central

Zaghloul, Ashraf Ahmad; Rahman, Syed Azizur; Abou El-Enein, Nagwa Younes

2016-01-01

OBJECTIVE: The study aimed to identify healthcare providers’ obligation towards medical errors disclosure as well as to study the association between the severity of the medical error and the intention to disclose the error to the patients and their families. DESIGN: A cross-sectional study design was followed to identify the magnitude of disclosure among healthcare providers in different departments at a randomly selected tertiary care hospital in Dubai. SETTING AND PARTICIPANTS: The total sample size accounted for 106 respondents. Data were collected using a questionnaire composed of two sections namely; demographic variables of the respondents and a section which included variables relevant to medical error disclosure. RESULTS: Statistical analysis yielded significant association between the obligation to disclose medical errors with male healthcare providers (X2 = 5.1), and being a physician (X2 = 19.3). Obligation towards medical errors disclosure was significantly associated with those healthcare providers who had not committed any medical errors during the past year (X2 = 9.8), and any type of medical error regardless the cause, extent of harm (X2 = 8.7). Variables included in the binary logistic regression model were; status (Exp β (Physician) = 0.39, 95% CI 0.16–0.97), gender (Exp β (Male) = 4.81, 95% CI 1.84–12.54), and medical errors during the last year (Exp β (None) = 2.11, 95% CI 0.6–2.3). CONCLUSION: Education and training of physicians about disclosure conversations needs to start as early as medical school. Like the training in other competencies required of physicians, education in communicating about medical errors could help reduce physicians’ apprehension and make them more comfortable with disclosure conversations. PMID:27567766

Current pulse: can a production system reduce medical errors in health care?

PubMed

Printezis, Antonios; Gopalakrishnan, Mohan

2007-01-01

One of the reasons for rising health care costs is medical errors, a majority of which result from faulty systems and processes. Health care in the past has used process-based initiatives such as Total Quality Management, Continuous Quality Improvement, and Six Sigma to reduce errors. These initiatives to redesign health care, reduce errors, and improve overall efficiency and customer satisfaction have had moderate success. Current trend is to apply the successful Toyota Production System (TPS) to health care since its organizing principles have led to tremendous improvement in productivity and quality for Toyota and other businesses that have adapted them. This article presents insights on the effectiveness of TPS principles in health care and the challenges that lie ahead in successfully integrating this approach with other quality initiatives.

The global burden of diagnostic errors in primary care.

PubMed

Singh, Hardeep; Schiff, Gordon D; Graber, Mark L; Onakpoya, Igho; Thompson, Matthew J

2017-06-01

Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care ', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Safety climate and its association with office type and team involvement in primary care.

PubMed

Gehring, Katrin; Schwappach, David L B; Battaglia, Markus; Buff, Roman; Huber, Felix; Sauter, Peter; Wieser, Markus

2013-09-01

To assess differences in safety climate perceptions between occupational groups and types of office organization in primary care. Primary care physicians and nurses working in outpatient offices were surveyed about safety climate. Explorative factor analysis was performed to determine the factorial structure. Differences in mean climate scores between staff groups and types of office were tested. Logistic regression analysis was conducted to determine predictors for a 'favorable' safety climate. 630 individuals returned the survey (response rate, 50%). Differences between occupational groups were observed in the means of the 'team-based error prevention'-scale (physician 4.0 vs. nurse 3.8, P < 0.001). Medical centers scored higher compared with single-handed offices and joint practices on the 'team-based error prevention'-scale (4.3 vs. 3.8 vs. 3.9, P < 0.001) but less favorable on the 'rules and risks'-scale (3.5 vs. 3.9 vs. 3.7, P < 0.001). Characteristics on the individual and office level predicted favorable 'team-based error prevention'-scores. Physicians (OR = 0.4, P = 0.01) and less experienced staff (OR 0.52, P = 0.04) were less likely to provide favorable scores. Individuals working at medical centers were more likely to provide positive scores compared with single-handed offices (OR 3.33, P = 0.001). The largest positive effect was associated with at least monthly team meetings (OR 6.2, P < 0.001) and participation in quality circles (OR 4.49, P < 0.001). Results indicate that frequent quality circle participation and team meetings involving all team members are effective ways to strengthen safety climate in terms of team-based strategies and activities in error prevention.

Human error and human factors engineering in health care.

PubMed

Welch, D L

1997-01-01

Human error is inevitable. It happens in health care systems as it does in all other complex systems, and no measure of attention, training, dedication, or punishment is going to stop it. The discipline of human factors engineering (HFE) has been dealing with the causes and effects of human error since the 1940's. Originally applied to the design of increasingly complex military aircraft cockpits, HFE has since been effectively applied to the problem of human error in such diverse systems as nuclear power plants, NASA spacecraft, the process control industry, and computer software. Today the health care industry is becoming aware of the costs of human error and is turning to HFE for answers. Just as early experimental psychologists went beyond the label of "pilot error" to explain how the design of cockpits led to air crashes, today's HFE specialists are assisting the health care industry in identifying the causes of significant human errors in medicine and developing ways to eliminate or ameliorate them. This series of articles will explore the nature of human error and how HFE can be applied to reduce the likelihood of errors and mitigate their effects.

The global burden of diagnostic errors in primary care

PubMed Central

Singh, Hardeep; Schiff, Gordon D; Graber, Mark L; Onakpoya, Igho; Thompson, Matthew J

2017-01-01

Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, ‘Improving Diagnosis in Health Care’, concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a ‘magic bullet’ and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO’s leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error. PMID:27530239

A multifaceted program for improving quality of care in intensive care units: IATROREF study.

PubMed

Garrouste-Orgeas, Maite; Soufir, Lilia; Tabah, Alexis; Schwebel, Carole; Vesin, Aurelien; Adrie, Christophe; Thuong, Marie; Timsit, Jean Francois

2012-02-01

To test the effects of three multifaceted safety programs designed to decrease insulin administration errors, anticoagulant prescription and administration errors, and errors leading to accidental removal of endotracheal tubes and central venous catheters, respectively. Medical errors and adverse events are associated with increased mortality in intensive care patients, indicating an urgent need for prevention programs. Multicenter cluster-randomized study. One medical intensive care unit in a university hospital and two medical-surgical intensive care units in community hospitals belonging to the Outcomerea Study Group. Consecutive patients >18 yrs admitted from January 2007 to January 2008 to the intensive care units. We tested three multifaceted safety programs vs. standard care in random order, each over 2.5 months, after a 1.5-month observation period. Incidence rates of medical errors/1000 patient-days in the multifaceted safety program and standard-care groups were compared using adjusted hierarchical models. In 2117 patients with 15,014 patient-days, 8520 medical errors (567.5/1000 patient-days) were reported, including 1438 adverse events (16.9%, 95.8/1000 patient-days). The insulin multifaceted safety program significantly decreased errors during implementation (risk ratio 0.65; 95% confidence interval [CI] 0.52-0.82; p = .0003) and after implementation (risk ratio 0.51; 95% CI 0.35-0.73; p = .0004). A significant Hawthorne effect was found. The accidental tube/catheter removal multifaceted safety program decreased errors significantly during implementation (odds ratio [OR] 0.34; 95% CI 0.15-0.81; p = .01]) and nonsignificantly after implementation (OR 1.65; 95% CI 0.78-3.48). The anticoagulation multifaceted safety program was not significantly effective (OR 0.64; 95% CI 0.26-1.59) but produced a significant Hawthorne effect. A multifaceted program was effective in preventing insulin errors and accidental tube/catheter removal. Significant Hawthorne effects occurred, emphasizing the need for appropriately designed studies before definitively implementing strategies. clinicaltrials.gov Identifier: NCT00461461.

Medication errors in outpatient care in Colombia, 2005-2013.

PubMed

Machado-Alba, Jorge E; Moncada, Juan Carlos; Moreno-Gutiérrez, Paula Andrea

2016-06-03

Medication errors outside the hospital have been poorly studied despite representing an important threat to patient safety. To describe the characteristics of medication errors in outpatient dispensing pharmacists reported in a pharmaco-surveillance system between 2005 and 2013 in Colombia. We conducted a descriptive study by reviewing and categorizing medication error reports from outpatient pharmacy services to a national medication dispensing company between January, 2005 and September, 2013. Variables considered included: process involved (administration, dispensing, prescription and transcription), wrong drug, time delay for the report, error type, cause and severity. The analysis was conducted in the SPSS® software, version 22.0. A total of 14,873 medication errors were reviewed, of which 67.2% in fact occurred, 15.5% reached the patient and 0.7% caused harm. Administration (OR=93.61, CI 95%: 48.510-180.655, p<0.001), dispensing (OR=21.58, CI 95%: 16.139-28.870, p<0.001), transcription errors (OR=5.64; CI 95%: 3.488-9.142, p<0.001), medicines for sensory organs (OR=2.04, CI 95%: 1.519-2.756, p<0.001), anti-infective drugs for systemic use (OR=1.99, CI 95%: 1.574-2.525, p0.001), confusion generated with the name of the drug (OR=1.28, CI 95%: 1.051-1.560, p=0.014), and trouble interpreting prescriptions (OR=1.32, CI 95%: 1.037-1.702, p=0.025) increased the risk for error reaching the patient. It is necessary to develop surveillance systems for medication errors in ambulatory care, focusing on the prescription, transcription and dispensation processes. Special strategies are needed for the prevention of medication errors related to anti-infective drugs.

PROTECTED-UK - Clinical pharmacist interventions in the UK critical care unit: exploration of relationship between intervention, service characteristics and experience level.

PubMed

Rudall, Nicola; McKenzie, Catherine; Landa, June; Bourne, Richard S; Bates, Ian; Shulman, Rob

2017-08-01

Clinical pharmacist (CP) interventions from the PROTECTED-UK cohort, a multi-site critical care interventions study, were further analysed to assess effects of: time on critical care, number of interventions, CP expertise and days of week, on impact of intervention and ultimately contribution to patient care. Intervention data were collected from 21 adult critical care units over 14 days. Interventions could be error, optimisation or consults, and were blind-coded to ensure consistency, prior to bivariate analysis. Pharmacy service demographics were further collated by investigator survey. Of the 20 758 prescriptions reviewed, 3375 interventions were made (intervention rate 16.1%). CPs spent 3.5 h per day (mean, ±SD 1.7) on direct patient care, reviewed 10.3 patients per day (±SD 4.2) and required 22.5 min (±SD 9.5) per review. Intervention rate had a moderate inverse correlation with the time the pharmacist spent on critical care (P = 0.05; r = 0.4). Optimisation rate had a strong inverse association with total number of prescriptions reviewed per day (P = 0.001; r = 0.7). A consultant CP had a moderate inverse correlation with number of errors identified (P = 0.008; r = 0.6). No correlation existed between the presence of electronic prescribing in critical care and any intervention rate. Few centres provided weekend services, although the intervention rate was significantly higher on weekends than weekdays. A CP is essential for safe and optimised patient medication therapy; an extended and developed pharmacy service is expected to reduce errors. CP services should be adequately staffed to enable adequate time for prescription review and maximal therapy optimisation. © 2016 Royal Pharmaceutical Society.

Common but unappreciated sources of error in one, two, and multiple-color pyrometry

NASA Technical Reports Server (NTRS)

Spjut, R. Erik

1988-01-01

The most common sources of error in optical pyrometry are examined. They can be classified as either noise and uncertainty errors, stray radiation errors, or speed-of-response errors. Through judicious choice of detectors and optical wavelengths the effect of noise errors can be minimized, but one should strive to determine as many of the system properties as possible. Careful consideration of the optical-collection system can minimize stray radiation errors. Careful consideration must also be given to the slowest elements in a pyrometer when measuring rapid phenomena.

Reduction in Chemotherapy Mixing Errors Using Six Sigma: Illinois CancerCare Experience.

PubMed

Heard, Bridgette; Miller, Laura; Kumar, Pankaj

2012-03-01

Chemotherapy mixing errors (CTMRs), although rare, have serious consequences. Illinois CancerCare is a large practice with multiple satellite offices. The goal of this study was to reduce the number of CTMRs using Six Sigma methods. A Six Sigma team consisting of five participants (registered nurses and pharmacy technicians [PTs]) was formed. The team had 10 hours of Six Sigma training in the DMAIC (ie, Define, Measure, Analyze, Improve, Control) process. Measurement of errors started from the time the CT order was verified by the PT to the time of CT administration by the nurse. Data collection included retrospective error tracking software, system audits, and staff surveys. Root causes of CTMRs included inadequate knowledge of CT mixing protocol, inconsistencies in checking methods, and frequent changes in staffing of clinics. Initial CTMRs (n = 33,259) constituted 0.050%, with 77% of these errors affecting patients. The action plan included checklists, education, and competency testing. The postimplementation error rate (n = 33,376, annualized) over a 3-month period was reduced to 0.019%, with only 15% of errors affecting patients. Initial Sigma was calculated at 4.2; this process resulted in the improvement of Sigma to 5.2, representing a 100-fold reduction. Financial analysis demonstrated a reduction in annualized loss of revenue (administration charges and drug wastage) from $11,537.95 (Medicare Average Sales Price) before the start of the project to $1,262.40. The Six Sigma process is a powerful technique in the reduction of CTMRs.

Cannonical [sic] confusions, an illusory allusion, and more: a critique of Haggbloom, et al.'s list of eminent psychologists (2002).

PubMed

Black, Stephen L

2003-06-01

The analysis by Haggbloom, et al. (2002) establishing a list of the most eminent psychologists of the 20th century contains significant errors. In one case the achievements of Walter B. Cannon are misattributed to W. Gary Cannon. Other errors are eponyms misattributed to Margaret F. Washburn, Morton Deutsch, Wolfgang Köhler, and G. Stanley Hall. A further mistake is to miscalculate the statistic for introductory psychology textbook citations for Hans J. Eysenck. These errors have consequences for the ranking of individuals on this list. Care must be taken to guard against such mistakes.

Using Broken Windows Theory as the Backdrop for a Proactive Approach to Threat Identification in Health Care.

PubMed

Boquet, Albert J; Cohen, Tara N; Cabrera, Jennifer S; Litzinger, Tracy L; Captain, Kevin A; Fabian, Michael A; Miles, Steven G; Shappell, Scott A

2016-09-09

Historically, health care has relied on error management techniques to measure and reduce the occurrence of adverse events. This study proposes an alternative approach for identifying and analyzing hazardous events. Whereas previous research has concentrated on investigating individual flow disruptions, we maintain the industry should focus on threat windows, or the accumulation of these disruptions. This methodology, driven by the broken windows theory, allows us to identify process inefficiencies before they manifest and open the door for the occurrence of errors and adverse events. Medical human factors researchers observed disruptions during 34 trauma cases at a Level II trauma center. Data were collected during resuscitation and imaging and were classified using a human factors taxonomy: Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis (RIPCHORD-TWA). Of the 576 total disruptions observed, communication issues were the most prevalent (28%), followed by interruptions and coordination issues (24% each). Issues related to layout (16%), usability (5%), and equipment (2%) comprised the remainder of the observations. Disruptions involving communication issues were more prevalent during resuscitation, whereas coordination problems were observed more frequently during imaging. Rather than solely investigating errors and adverse events, we propose conceptualizing the accumulation of disruptions in terms of threat windows as a means to analyze potential threats to the integrity of the trauma care system. This approach allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.

The underreporting of medication errors: A retrospective and comparative root cause analysis in an acute mental health unit over a 3-year period.

PubMed

Morrison, Maeve; Cope, Vicki; Murray, Melanie

2018-05-15

Medication errors remain a commonly reported clinical incident in health care as highlighted by the World Health Organization's focus to reduce medication-related harm. This retrospective quantitative analysis examined medication errors reported by staff using an electronic Clinical Incident Management System (CIMS) during a 3-year period from April 2014 to April 2017 at a metropolitan mental health ward in Western Australia. The aim of the project was to identify types of medication errors and the context in which they occur and to consider recourse so that medication errors can be reduced. Data were retrieved from the Clinical Incident Management System database and concerned medication incidents from categorized tiers within the system. Areas requiring improvement were identified, and the quality of the documented data captured in the database was reviewed for themes pertaining to medication errors. Content analysis provided insight into the following issues: (i) frequency of problem, (ii) when the problem was detected, and (iii) characteristics of the error (classification of drug/s, where the error occurred, what time the error occurred, what day of the week it occurred, and patient outcome). Data were compared to the state-wide results published in the Your Safety in Our Hands (2016) report. Results indicated several areas upon which quality improvement activities could be focused. These include the following: structural changes; changes to policy and practice; changes to individual responsibilities; improving workplace culture to counteract underreporting of medication errors; and improvement in safety and quality administration of medications within a mental health setting. © 2018 Australian College of Mental Health Nurses Inc.

The next organizational challenge: finding and addressing diagnostic error.

PubMed

Graber, Mark L; Trowbridge, Robert; Myers, Jennifer S; Umscheid, Craig A; Strull, William; Kanter, Michael H

2014-03-01

Although health care organizations (HCOs) are intensely focused on improving the safety of health care, efforts to date have almost exclusively targeted treatment-related issues. The literature confirms that the approaches HCOs use to identify adverse medical events are not effective in finding diagnostic errors, so the initial challenge is to identify cases of diagnostic error. WHY HEALTH CARE ORGANIZATIONS NEED TO GET INVOLVED: HCOs are preoccupied with many quality- and safety-related operational and clinical issues, including performance measures. The case for paying attention to diagnostic errors, however, is based on the following four points: (1) diagnostic errors are common and harmful, (2) high-quality health care requires high-quality diagnosis, (3) diagnostic errors are costly, and (4) HCOs are well positioned to lead the way in reducing diagnostic error. FINDING DIAGNOSTIC ERRORS: Current approaches to identifying diagnostic errors, such as occurrence screens, incident reports, autopsy, and peer review, were not designed to detect diagnostic issues (or problems of omission in general) and/or rely on voluntary reporting. The realization that the existing tools are inadequate has spurred efforts to identify novel tools that could be used to discover diagnostic errors or breakdowns in the diagnostic process that are associated with errors. New approaches--Maine Medical Center's case-finding of diagnostic errors by facilitating direct reports from physicians and Kaiser Permanente's electronic health record--based reports that detect process breakdowns in the followup of abnormal findings--are described in case studies. By raising awareness and implementing targeted programs that address diagnostic error, HCOs may begin to play an important role in addressing the problem of diagnostic error.

An educational and audit tool to reduce prescribing error in intensive care.

PubMed

Thomas, A N; Boxall, E M; Laha, S K; Day, A J; Grundy, D

2008-10-01

To reduce prescribing errors in an intensive care unit by providing prescriber education in tutorials, ward-based teaching and feedback in 3-monthly cycles with each new group of trainee medical staff. Prescribing audits were conducted three times in each 3-month cycle, once pretraining, once post-training and a final audit after 6 weeks. The audit information was fed back to prescribers with their correct prescribing rates, rates for individual error types and total error rates together with anonymised information about other prescribers' error rates. The percentage of prescriptions with errors decreased over each 3-month cycle (pretraining 25%, 19%, (one missing data point), post-training 23%, 6%, 11%, final audit 7%, 3%, 5% (p<0.0005)). The total number of prescriptions and error rates varied widely between trainees (data collection one; cycle two: range of prescriptions written: 1-61, median 18; error rate: 0-100%; median: 15%). Prescriber education and feedback reduce manual prescribing errors in intensive care.

Understanding diagnostic errors in medicine: a lesson from aviation

PubMed Central

Singh, H; Petersen, L A; Thomas, E J

2006-01-01

The impact of diagnostic errors on patient safety in medicine is increasingly being recognized. Despite the current progress in patient safety research, the understanding of such errors and how to prevent them is inadequate. Preliminary research suggests that diagnostic errors have both cognitive and systems origins. Situational awareness is a model that is primarily used in aviation human factors research that can encompass both the cognitive and the systems roots of such errors. This conceptual model offers a unique perspective in the study of diagnostic errors. The applicability of this model is illustrated by the analysis of a patient whose diagnosis of spinal cord compression was substantially delayed. We suggest how the application of this framework could lead to potential areas of intervention and outline some areas of future research. It is possible that the use of such a model in medicine could help reduce errors in diagnosis and lead to significant improvements in patient care. Further research is needed, including the measurement of situational awareness and correlation with health outcomes. PMID:16751463

Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation, and Response to Medical Errors.

PubMed

Dreisinger, Naomi; Zapolsky, Nathan

2017-02-01

The emergency department (ED) is an environment that is conducive to medical errors. The ED is a time-pressured environment where physicians aim to rapidly evaluate and treat patients. Quick thinking and problem-based solutions are often used to assist in evaluation and diagnosis. Error analysis leads to an understanding of the cause of a medical error and is important to prevent future errors. Research suggests mechanisms to prevent medical errors in the pediatric ED, but prevention is not always possible. Transparency about errors is necessary to assure a trusting doctor-patient relationship. Patients want to be informed about all errors, and apologies are hard. Apologizing for a significant medical error that may have caused a complication is even harder. Having a systematic way to go about apologizing makes the process easier, and helps assure that the right information is relayed to the patient and his or her family. This creates an environment of autonomy and shared decision making that is ultimately beneficial to all aspects of patient care.

The relationship between external and local governance systems: the case of health care associated infections and medication errors in one NHS trust.

PubMed

Ramsay, Angus; Magnusson, Carin; Fulop, Naomi

2010-12-01

'Organisational governance'--the systems, processes, behaviours and cultures by which an organisation leads and controls its functions to achieve its objectives--is seen as an important influence on patient safety. The features of 'good' governance remain to be established, partly because the relationship between governance and safety requires more investigation. To describe external governance systems--for example, national targets and regulatory bodies--and an NHS Trust's formal governance systems for Health Care Associated Infections (HCAIs) and medication errors; to consider the relationships between these systems. External governance systems and formal internal governance systems for both medication errors and HCAIs were analysed based on documentary analysis and interviews with relevant hospital staff. Nationally, HCAIs appeared to be a higher priority than medication errors, reflected in national targets and the focus of regulatory bodies. Locally, HCAIs were found to be the focus of committees at all levels of the organisation and, unlike medication errors, a central component of the Trust's performance management system; medication errors were discussed in appropriate governance committees, but most governance of medication errors took place at divisional or ward level. The data suggest a relationship between national and local prioritisation of the safety issues examined: national targets on HCAIs influence the behaviour of regulators and professional organisations; and these, in turn, have a significant impact on Trust activity. A contributory factor might be that HCAIs are more amenable to measurement than medication errors, meaning HCAIs lend themselves better to target-setting.

Analysis of all-optical temporal integrator employing phased-shifted DFB-SOA.

PubMed

Jia, Xin-Hong; Ji, Xiao-Ling; Xu, Cong; Wang, Zi-Nan; Zhang, Wei-Li

2014-11-17

All-optical temporal integrator using phase-shifted distributed-feedback semiconductor optical amplifier (DFB-SOA) is investigated. The influences of system parameters on its energy transmittance and integration error are explored in detail. The numerical analysis shows that, enhanced energy transmittance and integration time window can be simultaneously achieved by increased injected current in the vicinity of lasing threshold. We find that the range of input pulse-width with lower integration error is highly sensitive to the injected optical power, due to gain saturation and induced detuning deviation mechanism. The initial frequency detuning should also be carefully chosen to suppress the integration deviation with ideal waveform output.

A Case of Error Disclosure: A Communication Privacy Management Analysis

PubMed Central

Petronio, Sandra; Helft, Paul R.; Child, Jeffrey T.

2013-01-01

To better understand the process of disclosing medical errors to patients, this research offers a case analysis using Petronios’s theoretical frame of Communication Privacy Management (CPM). Given the resistance clinicians often feel about error disclosure, insights into the way choices are made by the clinicians in telling patients about the mistake has the potential to address reasons for resistance. Applying the evidenced-based CPM theory, developed over the last 35 years and dedicated to studying disclosure phenomenon, to disclosing medical mistakes potentially has the ability to reshape thinking about the error disclosure process. Using a composite case representing a surgical mistake, analysis based on CPM theory is offered to gain insights into conversational routines and disclosure management choices of revealing a medical error. The results of this analysis show that an underlying assumption of health information ownership by the patient and family can be at odds with the way the clinician tends to control disclosure about the error. In addition, the case analysis illustrates that there are embedded patterns of disclosure that emerge out of conversations the clinician has with the patient and the patient’s family members. These patterns unfold privacy management decisions on the part of the clinician that impact how the patient is told about the error and the way that patients interpret the meaning of the disclosure. These findings suggest the need for a better understanding of how patients manage their private health information in relationship to their expectations for the way they see the clinician caring for or controlling their health information about errors. Significance for public health Much of the mission central to public health sits squarely on the ability to communicate effectively. This case analysis offers an in-depth assessment of how error disclosure is complicated by misunderstandings, assuming ownership and control over information, unwittingly following conversational scripts that convey misleading messages, and the difficulty in regulating privacy boundaries in the stressful circumstances that occur with error disclosures. As a consequence, the potential contribution to public health is the ability to more clearly see the significance of the disclosure process that has implications for many public health issues. PMID:25170501

Technology-related medication errors in a tertiary hospital: a 5-year analysis of reported medication incidents.

PubMed

Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y

2012-12-01

Healthcare technology is meant to reduce medication errors. The objective of this study was to assess unintended errors related to technologies in the medication use process. Medication incidents reported from 2006 to 2010 in a main tertiary care hospital were analysed by a pharmacist and technology-related errors were identified. Technology-related errors were further classified as socio-technical errors and device errors. This analysis was conducted using data from medication incident reports which may represent only a small proportion of medication errors that actually takes place in a hospital. Hence, interpretation of results must be tentative. 1538 medication incidents were reported. 17.1% of all incidents were technology-related, of which only 1.9% were device errors, whereas most were socio-technical errors (98.1%). Of these, 61.2% were linked to computerised prescription order entry, 23.2% to bar-coded patient identification labels, 7.2% to infusion pumps, 6.8% to computer-aided dispensing label generation and 1.5% to other technologies. The immediate causes for technology-related errors included, poor interface between user and computer (68.1%), improper procedures or rule violations (22.1%), poor interface between user and infusion pump (4.9%), technical defects (1.9%) and others (3.0%). In 11.4% of the technology-related incidents, the error was detected after the drug had been administered. A considerable proportion of all incidents were technology-related. Most errors were due to socio-technical issues. Unintended and unanticipated errors may happen when using technologies. Therefore, when using technologies, system improvement, awareness, training and monitoring are needed to minimise medication errors. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Reducing medication errors and increasing patient safety: case studies in clinical pharmacology.

PubMed

Benjamin, David M

2003-07-01

Today, reducing medication errors and improving patient safety have become common topics of discussion for the president of the United States, federal and state legislators, the insurance industry, pharmaceutical companies, health care professionals, and patients. But this is not news to clinical pharmacologists. Improving the judicious use of medications and minimizing adverse drug reactions have always been key areas of research and study for those working in clinical pharmacology. However, added to the older terms of adverse drug reactions and rational therapeutics, the now politically correct expression of medication error has emerged. Focusing on the word error has drawn attention to "prevention" and what can be done to minimize mistakes and improve patient safety. Webster's New Collegiate Dictionary has several definitions of error, but the one that seems to be most appropriate in the context of medication errors is "an act that through ingnorance, deficiency, or accident departs from or fails to achieve what should be done." What should be done is generally known as "the five rights": the right drug, right dose, right route, right time, and right patient. One can make an error of omission (failure to act correctly) or an error of commission (acted incorrectly). This article now summarizes what is currently known about medication errors and translates the information into case studies illustrating common scenarios leading to medication errors. Each case is analyzed to provide insight into how the medication error could have been prevented. "System errors" are described, and the application of failure mode effect analysis (FMEA) is presented to determine the part of the "safety net" that failed. Examples of reengineering the system to make it more "error proof" are presented. An error can be prevented. However, the practice of medicine, pharmacy, and nursing in the hospital setting is very complicated, and so many steps occur from "pen to patient" that there is a lot to analyze. Implementing safer practices requires developing safer systems. Many errors occur as a result of poor oral or written communications. Enhanced communication skills and better interactions among members of the health care team and the patient are essential. The informed consent process should be used as a patient safety tool, and the patient should be warned about material and foreseeable serious side effects and be told what signs and symptoms should be immediately reported to the physician before the patient is forced to go to the emergency department for urgent or emergency care. Last, reducing medication errors is an ongoing process of quality improvement. Faculty systems must be redesigned, and seamless, computerized integrated medication delivery must be instituted by health care professionals adequately trained to use such technological advances. Sloppy handwritten prescriptions should be replaced by computerized physician order entry, a very effective technique for reducing prescribing/ordering errors, but another far less expensive yet effective change would involve writing all drug orders in plain English, rather than continuing to use the elitists' arcane Latin words and shorthand abbreviations that are subject to misinterpretation. After all, effective communication is best accomplished when it is clear and simple.

The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.

PubMed

Panesar, Sukhmeet S; Netuveli, Gopalakrishnan; Carson-Stevens, Andrew; Javad, Sundas; Patel, Bhavesh; Parry, Gareth; Donaldson, Liam J; Sheikh, Aziz

2013-11-21

The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery. Cross-sectional study (retrospective analysis of records in a database). The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties. We extracted all orthopaedic error reports from the system over 1 year (2009-2010). The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention. 155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively. The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.

Partnerships With Aviation: Promoting a Culture of Safety in Health Care.

PubMed

Skinner, Lori; Tripp, Terrance R; Scouler, David; Pechacek, Judith M

2015-01-01

According to the Institute of Medicine (IOM, 1999, p. 1), "Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." The current health care culture is disjointed, as evidenced by a lack of consistent reporting standards for all providers; provider licensing pays little attention to errors, and there are no financial incentives to improve safety (IOM, 1999). Many errors in health care are preventable. "Near misses" and adverse events that do occur can offer insight on how to improve practice and prevent future events. The aim of this article is to better understand underreporting of errors in health care, to present a model of change that increases voluntary error reporting, and to discuss the role nurse executives play in creating a culture of safety. This article explores how high reliability organizations such as aviation improve safety through enhanced error reporting, culture change, and teamwork.

[Prevention of medication errors in healthcare transition of patients treated with apomorphine].

PubMed

Ucha Sanmartin, M; Martín Vila, A; López Vidal, C; Caaamaño Barreiro, M; Piñeiro Corrales, G

2014-05-01

The transition of patients between different levels of care process is a particular risk in the production of medication errors. The aim of this paper is to analyze the role of the pharmacist in preventing errors transition care to ensure a safe and cross pharmacotherapy of patients.Transversal, observational and descriptive study in a University Hospital that has a pharmacy service that integrates specialized inpatient care and health centers. Transition of care a patient treated with Apormorfina was analyzed to determine the keypoints of action of the pharmacist. Demographics, disease and medication history, and care transition episodes were collected through the pharmacy program and electronics history.The pharmacist did tasks adapting, reconciliation, management and reporting of medication to the health care team to prevent medication errors in care transition of patients treated with drugs requiring special handling .In conclusion, this work represents perfectly the key role of the pharmacist as coordinator of safe and transverse pharmacotherapy of patients. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

MALPRACTICE AND THE QUALITY OF CARE IN RETINOPATHY OF PREMATURITY (AN AMERICAN OPHTHALMOLOGICAL SOCIETY THESIS)

PubMed Central

Reynolds, James D.

2007-01-01

Purpose A review of retinopathy of prematurity (ROP) malpractice cases will identify specific, repetitive problems in the provision of care and the reasons underlying these problems. Opportunities to improve the quality of care provided to premature infants with ROP will result. Methods A retrospective review of a series of 13 ROP malpractice cases in which the author served as a paid consultant, as well as a review of the literature for additional cases, was conducted. The series of 13 involved a review of the entire medical record as well as testimony and depositions. The characteristics of each case are tabulated, including state, date, allegations, defendants, disposition, award, the medical facts and care issues involved, and the judgment of medical error. In addition, a merit review was performed on the care in each case, and an error assessment was performed. Results The quality of care issues included neonatology failure to refer or follow up in 8 of 13, failure to adequately supervise resident care in 2 of 13, ophthalmologic failure to follow up in 6 of 13, and failure to properly diagnose and manage in 9 of 13. The latter included 4 of 13 that hinged on zone III issues and the presence or absence of full nasal vascularization with or without previous zone II disease. Merit review found negligent error by at least one party in 12 of 13. Ophthalmology error was found in 6 of 13. Malpractice, ie, negligent error causing negligent harm, was judged to be present in 9 of 13. Conclusions Negligent errors are common in malpractice cases that proceed to disposition. There are a limited number of repetitive errors that produce malpractice. An explanation of how these errors occur, coupled with the pertinent pathophysiology, afford an excellent opportunity to improve patient care PMID:18427626

The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong.

PubMed

Samaranayake, N R; Cheung, S T D; Chui, W C M; Cheung, B M Y

2013-06-01

The primary goal of reducing medication errors is to eliminate those that reach the patient. We aimed to study the pattern of interceptions to tackle medication errors along the medication use processes. Tertiary care hospital in Hong Kong. The 'Swiss Cheese Model' was used to explain the interceptions targeting medication error reporting over 5 years (2006-2010). Proportions of prescribing, dispensing and drug administration errors intercepted by pharmacists and nurses; proportions of prescribing, dispensing and drug administration errors that reached the patient. Our analysis included 1,268 in-patient medication errors, of which 53.4% were related to prescribing, 29.0% to administration and 17.6% to dispensing. 34.1% of all medication errors (4.9% prescribing, 26.8% drug administration and 2.4% dispensing) were not intercepted. Pharmacy staff intercepted 85.4% of the prescribing errors. Nurses detected 83.0% of dispensing and 5.0% of prescribing errors. However, 92.4% of all drug administration errors reached the patient. Having a preventive measure at each stage of the medication use process helps to prevent most errors. Most drug administration errors reach the patient as there is no defense against these. Therefore, more interventions to prevent drug administration errors are warranted.

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia.

PubMed

Martin, Lizabeth D; Grigg, Eliot B; Verma, Shilpa; Latham, Gregory J; Rampersad, Sally E; Martin, Lynn D

2017-06-01

The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety. © 2017 John Wiley & Sons Ltd.

Applied Strategies for Improving Patient Safety: A Comprehensive Process To Improve Care in Rural and Frontier Communities

ERIC Educational Resources Information Center

Westfall, John M.; Fernald, Douglas H.; Staton, Elizabeth W.; VanVorst, Rebecca; West, David; Pace, Wilson D.

2004-01-01

Medical errors and patient safety have gained increasing attention throughout all areas of medical care. Understanding patient safety in rural settings is crucial for improving care in rural communities. To describe a system to decrease medical errors and improve care in rural and frontier primary care offices. Applied Strategies for Improving…

Learning from Errors at Work: A Replication Study in Elder Care Nursing

ERIC Educational Resources Information Center

Leicher, Veronika; Mulder, Regina H.; Bauer, Johannes

2013-01-01

Learning from errors is an important way of learning at work. In this article, we analyse conditions under which elder care nurses use errors as a starting point for the engagement in social learning activities (ESLA) in the form of joint reflection with colleagues on potential causes of errors and ways to prevent them in future. The goal of our…

Reducing Wrong Patient Selection Errors: Exploring the Design Space of User Interface Techniques

PubMed Central

Sopan, Awalin; Plaisant, Catherine; Powsner, Seth; Shneiderman, Ben

2014-01-01

Wrong patient selection errors are a major issue for patient safety; from ordering medication to performing surgery, the stakes are high. Widespread adoption of Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE) systems makes patient selection using a computer screen a frequent task for clinicians. Careful design of the user interface can help mitigate the problem by helping providers recall their patients’ identities, accurately select their names, and spot errors before orders are submitted. We propose a catalog of twenty seven distinct user interface techniques, organized according to a task analysis. An associated video demonstrates eighteen of those techniques. EHR designers who consider a wider range of human-computer interaction techniques could reduce selection errors, but verification of efficacy is still needed. PMID:25954415

Reducing wrong patient selection errors: exploring the design space of user interface techniques.

PubMed

Sopan, Awalin; Plaisant, Catherine; Powsner, Seth; Shneiderman, Ben

2014-01-01

Wrong patient selection errors are a major issue for patient safety; from ordering medication to performing surgery, the stakes are high. Widespread adoption of Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE) systems makes patient selection using a computer screen a frequent task for clinicians. Careful design of the user interface can help mitigate the problem by helping providers recall their patients' identities, accurately select their names, and spot errors before orders are submitted. We propose a catalog of twenty seven distinct user interface techniques, organized according to a task analysis. An associated video demonstrates eighteen of those techniques. EHR designers who consider a wider range of human-computer interaction techniques could reduce selection errors, but verification of efficacy is still needed.

Jeffrey Baldwin: A Thematic Analysis of Media Coverage and Implications for Social Work Practice

ERIC Educational Resources Information Center

Choate, Peter W.

2017-01-01

Jeffery Baldwin died in 2002 in the care of his maternal grandparents. The case received intense media attention at various times over an almost eight-year period. Along with other public documents, the media coverage permits an analysis of the practice errors by Child Protection Services that are related to the failure to protect Jeffrey. Nine…

45 CFR 98.102 - Content of Error Rate Reports.

Code of Federal Regulations, 2013 CFR

2013-10-01

....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

45 CFR 98.102 - Content of Error Rate Reports.

Code of Federal Regulations, 2014 CFR

2014-10-01

....102 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

45 CFR 98.102 - Content of Error Rate Reports.

Code of Federal Regulations, 2012 CFR

2012-10-01

....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

45 CFR 98.102 - Content of Error Rate Reports.

Code of Federal Regulations, 2011 CFR

2011-10-01

....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

Risk management systems for health care and safety development on transplantation: a review and a proposal.

PubMed

Pretagostini, R; Gabbrielli, F; Fiaschetti, P; Oliveti, A; Cenci, S; Peritore, D; Stabile, D

2010-05-01

Starting from the report on medical errors published in 1999 by the US Institute of Medicine, a number of different approaches to risk management have been developed for maximum risk reduction in health care activities. The health care authorities in many countries have focused attention on patient safety, employing action research programs that are based on quite different principles. We performed a systematic Medline research of the literature since 1999. The following key words were used, also combining boolean operators and medical subheading terms: "adverse event," "risk management," "error," and "governance." Studies published in the last 5 years were particularly classified in various groups: risk management in health care systems; safety in specific hospital activities; and health care institutions' official documents. Methods of action researches have been analysed and their characteristics compared. Their suitability for safety development in donation, retrieval, and transplantation processes were discussed in the reality of the Italian transplant network. Some action researches and studies were dedicated to entire national healthcare systems, whereas others focused on specific risks. Many research programs have undergone critical review in the literature. Retrospective analysis has centered on so-called sentinel events to particularly analyze only a minor portion of the organizational phenomena, which can be the origin of an adverse event, an incident, or an error. Sentinel events give useful information if they are studied in highly engineered and standardized organizations like laboratories or tissue establishments, but they show several limits in the analysis of organ donation, retrieval, and transplantation processes, which are characterized by prevailing human factors, with high intrinsic risk and variability. Thus, they are poorly effective to deliver sure elements to base safety management improvement programs, especially regarding multidisciplinary systems with high complexity. In organ transplantation, the possibility to increase safety seems greater using proactive research, mainly centred on organizational processes together with retrospective analyses but not limited to sentinel event reports. Copyright (c) 2010. Published by Elsevier Inc.

["Second victim" - error, crises and how to get out of it].

PubMed

von Laue, N; Schwappach, D; Hochreutener, M

2012-06-01

Medical errors do not only harm patients ("first victims"). Almost all health care professionals become a so-called "second victim" once in their career by being involved in a medical error. Studies show that error involvement can have a tremendous impact on health care workers leading to burnout, depression and professional crisis. Moreover persons involved in errors show a decline in job performance and jeopardize therefore patient safety. Blaming the person is one of the typical psychological reactions after an error happened as the attribution theory tells. The self-esteem gets stabilized if we can put blame on someone and pick out a scapegoat. But standing alone makes the emotional situation even worse. A vicious circle can evolve with tragic effect for the individual and negative implications for patient safety and the health care setting.

Burnout syndrome among non-consultant hospital doctors in Ireland: relationship with self-reported patient care.

PubMed

Sulaiman, Che Fatehah Che; Henn, Patrick; Smith, Simon; O'Tuathaigh, Colm M P

2017-10-01

Intensive workload and limited training opportunities for Irish non-consultant hospital doctors (NCHDs) has a negative effect on their health and well-being, and can result in burnout. Burnout affects physician performance and can lead to medical errors. This study examined the prevalence of burnout syndrome among Irish NCHDs and its association with self-reported medical error and poor quality of patient care. A cross-sectional quantitative survey-based design. All teaching hospitals affiliated with University College Cork. NCHDs of all grades and specialties. The following instruments were completed by all participants: Maslach Burnout Inventory-Human Service Survey (MBI-HSS), assessing three categories of burnout syndrome: Emotional exhaustion (EE), Personal Achievement (PA) and Depersonalization (DP); questions related to self-reported medical errors/poor patient care quality and socio-demographic information. Self-reported measures of burnout and poor quality of patient care. Prevalence of burnout among physicians (n = 265) was 26.4%. There was a significant gender difference for EE and DP, but none for PA. A positive weak correlation was observed between EE and DP with medical error or poor patient care. A negative association was reported between PA and medical error and reduced quality of patient care. Burnout is prevalent among NCHDs in Ireland. Burnout syndrome is associated with self-reported medical error and quality of care in this sample population. Measures need to be taken to address this issue, with a view to protecting health of NCHDs and maintaining quality of patient care. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: A prospective observational study.

PubMed

Gilmartin-Thomas, Julia Fiona-Maree; Smith, Felicity; Wolfe, Rory; Jani, Yogini

2017-07-01

No published study has been specifically designed to compare medication administration errors between original medication packaging and multi-compartment compliance aids in care homes, using direct observation. Compare the effect of original medication packaging and multi-compartment compliance aids on medication administration accuracy. Prospective observational. Ten Greater London care homes. Nurses and carers administering medications. Between October 2014 and June 2015, a pharmacist researcher directly observed solid, orally administered medications in tablet or capsule form at ten purposively sampled care homes (five only used original medication packaging and five used both multi-compartment compliance aids and original medication packaging). The medication administration error rate was calculated as the number of observed doses administered (or omitted) in error according to medication administration records, compared to the opportunities for error (total number of observed doses plus omitted doses). Over 108.4h, 41 different staff (35 nurses, 6 carers) were observed to administer medications to 823 residents during 90 medication administration rounds. A total of 2452 medication doses were observed (1385 from original medication packaging, 1067 from multi-compartment compliance aids). One hundred and seventy eight medication administration errors were identified from 2493 opportunities for error (7.1% overall medication administration error rate). A greater medication administration error rate was seen for original medication packaging than multi-compartment compliance aids (9.3% and 3.1% respectively, risk ratio (RR)=3.9, 95% confidence interval (CI) 2.4 to 6.1, p<0.001). Similar differences existed when comparing medication administration error rates between original medication packaging (from original medication packaging-only care homes) and multi-compartment compliance aids (RR=2.3, 95%CI 1.1 to 4.9, p=0.03), and between original medication packaging and multi-compartment compliance aids within care homes that used a combination of both medication administration systems (RR=4.3, 95%CI 2.7 to 6.8, p<0.001). A significant difference in error rate was not observed between use of a single or combination medication administration system (p=0.44). The significant difference in, and high overall, medication administration error rate between original medication packaging and multi-compartment compliance aids supports the use of the latter in care homes, as well as local investigation of tablet and capsule impact on medication administration errors and staff training to prevent errors occurring. As a significant difference in error rate was not observed between use of a single or combination medication administration system, common practice of using both multi-compartment compliance aids (for most medications) and original packaging (for medications with stability issues) is supported. Copyright © 2017 Elsevier Ltd. All rights reserved.

Changes to Hospital Inpatient Volume After Newspaper Reporting of Medical Errors.

PubMed

Fukuda, Haruhisa

2017-06-30

The aim of this study was to investigate the influence of medical error case reporting by national newspapers on inpatient volume at acute care hospitals. A case-control study was conducted using the article databases of 3 major Japanese newspapers with nationwide circulation between fiscal years 2012 and 2013. Data on inpatient volume at acute care hospitals were obtained from a Japanese government survey between fiscal years 2011 and 2014. Panel data were constructed and analyzed using a difference-in-differences design. Acute care hospitals in Japan. Hospitals named in articles that included the terms "medical error" and "hospital" were designated case hospitals, which were matched with control hospitals using corresponding locations, nurse-to-patient ratios, and bed numbers. Medical error case reporting in newspapers. Changes to hospital inpatient volume after error reports. The sample comprised 40 case hospitals and 40 control hospitals. Difference-in-differences analyses indicated that newspaper reporting of medical errors was not significantly associated (P = 0.122) with overall inpatient volume. Medical error case reporting by newspapers showed no influence on inpatient volume. Hospitals therefore have little incentive to respond adequately and proactively to medical errors. There may be a need for government intervention to improve the posterror response and encourage better health care safety.

Impact of clinical pharmacy interventions on medication error nodes.

PubMed

Chamoun, Nibal R; Zeenny, Rony; Mansour, Hanine

2016-12-01

Background Pharmacists' involvement in patient care has improved the quality of care and reduced medication errors. However, this has required a lot of work that could not have been accomplished without documentation of interventions. Several means of documenting errors have been proposed in the literature but without a consistent comprehensive process. Recently, the American College of Clinical Pharmacy (ACCP) recognized that pharmacy practice lacks a consistent process for direct patient care and discussed several options for a pharmaceutical care plan, essentially encompassing medication therapy assessment, development and implementation of a pharmaceutical care plan and finally evaluation of the outcome. Therefore, as per the recommendations of ACCP, we sought to retrospectively analyze interventions by grouping them according to medication related problems (MRP) and their nodes such as prescribing; administering; monitoring; documenting and dispensing. Objective The aim of this study is to report interventions according to medication error (ME) nodes and show the impact of pharmacy interventions in reducing MRPs. Setting The study was conducted at the cardiology and infectious diseases services at a teaching hospital located in Beirut, Lebanon. Methods Intervention documentation was completed by pharmacy students on infectious diseases and cardiology rotations then reviewed by clinical pharmacists with respective specialties. Before data analysis, a new pharmacy reporting sheet was developed in order to link interventions according to MRP. Then, MRPs were grouped in the five ME nodes. During the documentation process, whether MRP had reached the patient or not may have not been reported which prevented the classification to the corresponding medication error nodes as ME. Main outcome Reduction in medication related problems across all ME nodes. Results A total of n = 1174 interventions were documented. N = 1091 interventions were classified as MRPs. Interventions were analyzed per 1000 patient days and resulted in 340 medication related problem/1000 patient days. A 72 % reduction in MRP across all ME nodes was seen. The majority of interventions were in the field of cardiology followed by infectious disease related. When interventions per ME nodes were analyzed, a high percentage of intervention acceptance was noted across all nodes especially prescribing (68.30 %) monitoring (77.7 %) and in documenting errors (79.36 %). Conclusion The role of pharmacists in reducing preventable MRPs can be shown when pharmacy interventions are analyzed according to corresponding MRP and ME nodes.

Recognizing the Ordinary as Extraordinary: Insight Into the "Way We Work" to Improve Patient Safety Outcomes.

PubMed

Henneman, Elizabeth A

2017-07-01

The Institute of Medicine (now National Academy of Medicine) reports "To Err is Human" and "Crossing the Chasm" made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the "near miss" process and as the final safety net for the patient is of paramount importance. The nurse's role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies. ©2017 American Association of Critical-Care Nurses.

Ventilator-associated pneumonia: the influence of bacterial resistance, prescription errors, and de-escalation of antimicrobial therapy on mortality rates.

PubMed

Souza-Oliveira, Ana Carolina; Cunha, Thúlio Marquez; Passos, Liliane Barbosa da Silva; Lopes, Gustavo Camargo; Gomes, Fabiola Alves; Röder, Denise Von Dolinger de Brito

2016-01-01

Ventilator-associated pneumonia is the most prevalent nosocomial infection in intensive care units and is associated with high mortality rates (14-70%). This study evaluated factors influencing mortality of patients with Ventilator-associated pneumonia (VAP), including bacterial resistance, prescription errors, and de-escalation of antibiotic therapy. This retrospective study included 120 cases of Ventilator-associated pneumonia admitted to the adult adult intensive care unit of the Federal University of Uberlândia. The chi-square test was used to compare qualitative variables. Student's t-test was used for quantitative variables and multiple logistic regression analysis to identify independent predictors of mortality. De-escalation of antibiotic therapy and resistant bacteria did not influence mortality. Mortality was 4 times and 3 times higher, respectively, in patients who received an inappropriate antibiotic loading dose and in patients whose antibiotic dose was not adjusted for renal function. Multiple logistic regression analysis revealed the incorrect adjustment for renal function was the only independent factor associated with increased mortality. Prescription errors influenced mortality of patients with Ventilator-associated pneumonia, underscoring the challenge of proper Ventilator-associated pneumonia treatment, which requires continuous reevaluation to ensure that clinical response to therapy meets expectations. Copyright © 2016. Published by Elsevier Editora Ltda.

Comparison Between Doppler-Echocardiography and Uncalibrated Pulse Contour Method for Cardiac Output Measurement: A Multicenter Observational Study.

PubMed

Scolletta, Sabino; Franchi, Federico; Romagnoli, Stefano; Carlà, Rossella; Donati, Abele; Fabbri, Lea P; Forfori, Francesco; Alonso-Iñigo, José M; Laviola, Silvia; Mangani, Valerio; Maj, Giulia; Martinelli, Giampaolo; Mirabella, Lucia; Morelli, Andrea; Persona, Paolo; Payen, Didier

2016-07-01

Echocardiography and pulse contour methods allow, respectively, noninvasive and less invasive cardiac output estimation. The aim of the present study was to compare Doppler echocardiography with the pulse contour method MostCare for cardiac output estimation in a large and nonselected critically ill population. A prospective multicenter observational comparison study. The study was conducted in 15 European medicosurgical ICUs. We assessed cardiac output in 400 patients in whom an echocardiographic evaluation was performed as a routine need or for cardiocirculatory assessment. None. One echocardiographic cardiac output measurement was compared with the corresponding MostCare cardiac output value per patient, considering different ICU admission categories and clinical conditions. For statistical analysis, we used Bland-Altman and linear regression analyses. To assess heterogeneity in results of individual centers, Cochran Q, and the I statistics were applied. A total of 400 paired echocardiographic cardiac output and MostCare cardiac output measures were compared. MostCare cardiac output values ranged from 1.95 to 9.90 L/min, and echocardiographic cardiac output ranged from 1.82 to 9.75 L/min. A significant correlation was found between echocardiographic cardiac output and MostCare cardiac output (r = 0.85; p < 0.0001). Among the different ICUs, the mean bias between echocardiographic cardiac output and MostCare cardiac output ranged from -0.40 to 0.45 L/min, and the percentage error ranged from 13.2% to 47.2%. Overall, the mean bias was -0.03 L/min, with 95% limits of agreement of -1.54 to 1.47 L/min and a relative percentage error of 30.1%. The percentage error was 24% in the sepsis category, 26% in the trauma category, 30% in the surgical category, and 33% in the medical admission category. The final overall percentage error was 27.3% with a 95% CI of 22.2-32.4%. Our results suggest that MostCare could be an alternative to echocardiography to assess cardiac output in ICU patients with a large spectrum of clinical conditions.

[Phenylephrine dosing error in Intensive Care Unit. Case of the trimester].

PubMed

2013-01-01

A real clinical case reported to SENSAR is presented. A patient admitted to the surgical intensive care unit following a lung resection, suffered arterial hypotension. The nurse was asked to give the patient 1 mL of phenylephrine. A few seconds afterwards, the patient experienced a hypertensive crisis, which resolved spontaneously without damage. Thereafter, the nurse was interviewed and a dosing error was identified: she had mistakenly given the patient 1 mg of phenylephrine (1 mL) instead of 100 mcg (1 mL of the standard dilution, 1mg in 10 mL). The incident analysis revealed latent factors (event triggers) due to the lack of protocols and standard operating procedures, communication errors among team members (physician-nurse), suboptimal training, and underdeveloped safety culture. In order to preempt similar incidents in the future, the following actions were implemented in the surgical intensive care unit: a protocol for bolus and short lived infusions (<30 min) was developed and to close the communication gap through the adoption of communication techniques. The protocol was designed by physicians and nurses to standardize the administration of drugs with high potential for errors. To close the communication gap, repeated checks about saying and understanding was proposed ("closed loop"). Labeling syringes with the drug dilution was also recommended. Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.

A Just Culture Approach to Managing Medication Errors.

PubMed

Rogers, Erin; Griffin, Emily; Carnie, William; Melucci, Joseph; Weber, Robert J

2017-04-01

Medication errors continue to be a concern of health care providers and the public, in particular how to prevent harm from medication mistakes. Many health care workers are afraid to report errors for fear of retribution including the loss of professional licensure and even imprisonment. Most health care workers are silent, instead of admitting their mistake and discussing it openly with peers. This can result in further patient harm if the system causing the mistake is not identified and fixed; thus self-denial may have a negative impact on patient care outcomes. As a result, pharmacy leaders, in collaboration with others, must put systems in place that serve to prevent medication errors while promoting a "Just Culture" way of managing performance and outcomes. This culture must exist across disciplines and departments. Pharmacy leaders need to understand how to classify behaviors associated with errors, set realistic expectations, instill values for staff, and promote accountability within the workplace. This article reviews the concept of Just Culture and provides ways that pharmacy directors can use this concept to manage the degree of error in patient-centered pharmacy services.

"Bed Side" Human Milk Analysis in the Neonatal Intensive Care Unit: A Systematic Review.

PubMed

Fusch, Gerhard; Kwan, Celia; Kotrri, Gynter; Fusch, Christoph

2017-03-01

Human milk analyzers can measure macronutrient content in native breast milk to tailor adequate supplementation with fortifiers. This article reviews all studies using milk analyzers, including (i) evaluation of devices, (ii) the impact of different conditions on the macronutrient analysis of human milk, and (iii) clinical trials to improve growth. Results lack consistency, potentially due to systematic errors in the validation of the device, or pre-analytical sample preparation errors like homogenization. It is crucial to introduce good laboratory and clinical practice when using these devices; otherwise a non-validated clinical usage can severely affect growth outcomes of infants. Copyright © 2016 Elsevier Inc. All rights reserved.

Establishing a culture for patient safety - the role of education.

PubMed

Milligan, Frank J

2007-02-01

This paper argues that the process of making significant moves towards a patient safety culture requires changes in healthcare education. Improvements in patient safety are a shared international priority as too many errors and other forms of unnecessary harm are currently occurring in the process of caring for and treating patients. A description of the patient safety agenda is given followed by a brief analysis of human factors theory and its use in other safety critical industries, most notably aviation. The all too common problem of drug administration errors is used to illustrate the relevance of human factors theory to healthcare education with specific mention made of the Human Factors Analysis and Classification System (HFACS).

Critical Care Performance in a Simulated Military Aircraft Cabin Environment.

PubMed

McNeill, Margaret M

2018-04-01

Critical Care Air Transport Teams care for 5% to 10% of injured patients who are transported on military aircraft to definitive treatment facilities. Little is known about how the aeromedical evacuation environment affects care. To determine the effects of 2 stressors of flight, altitude-induced hypoxia and aircraft noise, and to examine the contributions of fatigue and clinical experience on cognitive and physiological performance of the Critical Care Air Transport Team. This repeated measures 2 × 2 × 4 factorial study included 60 military nurses. The participants completed a simulated patient care scenario under aircraft cabin noise and altitude conditions. Differences in cognitive and physiological performance were analyzed using repeated measures analysis of variance. A multiple regression model was developed to determine the independent contributions of fatigue and clinical experience. Critical care scores ( P = .02) and errors and omissions ( P = .047) were negatively affected by noise. Noise was associated with increased respiratory rate ( P = .02). Critical care scores ( P < .001) and errors and omissions ( P = .002) worsened with altitude-induced hypoxemia. Heart rate and respiratory rate increased with altitude-induced hypoxemia; oxygen saturation decreased ( P < .001 for all 3 variables). In a simulated military aircraft environment, the care of critically ill patients was significantly affected by noise and altitude-induced hypoxemia. The participants did not report much fatigue and experience did not play a role, contrary to most findings in the literature. ©2018 American Association of Critical-Care Nurses.

A mixed-methods analysis of patient reviews of hospital care in England: implications for public reporting of health care quality data in the United States.

PubMed

Lagu, Tara; Goff, Sarah L; Hannon, Nicholas S; Shatz, Amy; Lindenauer, Peter K

2013-01-01

In the United States patients have limited opportunities to read and write narrative reviews about hospitals. In contrast, the National Health Service (NHS) in England encourages patients to provide feedback to hospitals on their quality-reporting website, NHS Choices. The scope and content of the narrative feedback was studied. All NHS hospitals with more than 10 reviews posted on NHS Choices were included in a cross-sectional mixed-methods (qualitative and quantitative) analysis of patients' reviews of 20 randomly selected hospitals. The final sample consisted of 264 hospitals and 2,640 patient responses to structured questions. All 200 reviews from the 20 hospitals randomly selected were subjected to further quantitative and qualitative analysis. Comments about clinicians and staff were common (179 [90%]) and overwhelmingly positive, with 149 (83%) favorable to workers. In 124 (62%) of the 200 reviews, patients commented on technical aspects of hospital care, including quality of care, injuries, errors, and incorrect medical record or discharge documentation. Perceived medical errors were described in 51 (26%) hospital reviews. Comments about the hospital facility appeared in half (52%) of reviews, describing hospital cleanliness, food, parking, and amenities. Hospitals replied to 56% of the patient reviews. NHS Choices represents the first government-run initiative that enables any patient to provide narrative feedback about hospital care. Reviews appear to have similar domains to those covered in existing satisfaction surveys but also include detailed feedback that would be unlikely to be revealed by such surveys. Online narrative reviews can therefore provide useful and complementary information to consumers (patients) and hospitals, particularly when combined with systematically collected patient experience data.

Report on Automated Semantic Analysis of Scientific and Engineering Codes

NASA Technical Reports Server (NTRS)

Stewart. Maark E. M.; Follen, Greg (Technical Monitor)

2001-01-01

The loss of the Mars Climate Orbiter due to a software error reveals what insiders know: software development is difficult and risky because, in part, current practices do not readily handle the complex details of software. Yet, for scientific software development the MCO mishap represents the tip of the iceberg; few errors are so public, and many errors are avoided with a combination of expertise, care, and testing during development and modification. Further, this effort consumes valuable time and resources even when hardware costs and execution time continually decrease. Software development could use better tools! This lack of tools has motivated the semantic analysis work explained in this report. However, this work has a distinguishing emphasis; the tool focuses on automated recognition of the fundamental mathematical and physical meaning of scientific code. Further, its comprehension is measured by quantitatively evaluating overall recognition with practical codes. This emphasis is necessary if software errors-like the MCO error-are to be quickly and inexpensively avoided in the future. This report evaluates the progress made with this problem. It presents recommendations, describes the approach, the tool's status, the challenges, related research, and a development strategy.

The spectrum of medical errors: when patients sue

PubMed Central

Kels, Barry D; Grant-Kels, Jane M

2012-01-01

Inarguably medical errors constitute a serious, dangerous, and expensive problem for the twenty-first-century US health care system. This review examines the incidence, nature, and complexity of alleged medical negligence and medical malpractice. The authors hope this will constitute a road map to medical providers so that they can better understand the present climate and hopefully avoid the “Scylla and Charybdis” of medical errors and medical malpractice. Despite some documented success in reducing medical errors, adverse events and medical errors continue to represent an indelible stain upon the practice, reputation, and success of the US health care industry. In that regard, what may be required to successfully attack the unacceptably high severity and volume of medical errors is a locally directed and organized initiative sponsored by individual health care organizations that is coordinated, supported, and guided by state and federal governmental and nongovernmental agencies. PMID:22924008

Triage: an investigation of the process and potential vulnerabilities.

PubMed

Hitchcock, Maree; Gillespie, Brigid; Crilly, Julia; Chaboyer, Wendy

2014-07-01

To explore and describe the triage process in the Emergency Department to identify problems and potential vulnerabilities that may affect the triage process. Triage is the first step in the patient journey in the Emergency Department and is often the front line in reducing the potential for errors and mistakes. A fieldwork study to provide an in-depth appreciation and understanding of the triage process. Fieldwork included unstructured observer-only observation, field notes, informal and formal interviews that were conducted over the months of June, July and August 2012. Over 170 hours of observation were performed covering day, evening and night shifts, 7 days of the week. Sixty episodes of triage were observed; 31 informal interviews and 14 formal interviews were completed. Thematic analysis was used. Three themes were identified from the analysis of the data and included: 'negotiating patient flow and care delivery through the Emergency Department'; 'interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients'; and 'varying levels of competence of the triage nurse'. In these themes, vulnerabilities and problems described included over and under triage, extended time to triage assessment, triage errors, multiple patients arriving simultaneously, emergency department and hospital overcrowding. Findings suggest that vulnerabilities in the triage process may cause disruptions to patient flow and compromise care, thus potentially impacting nurses' ability to provide safe and effective care. © 2013 John Wiley & Sons Ltd.

Guidelines for overcoming hospital managerial challenges: a systematic literature review

PubMed Central

Crema, Maria; Verbano, Chiara

2013-01-01

Purpose The need to respond to accreditation institutes’ and patients’ requirements and to align health care results with increased medical knowledge is focusing greater attention on quality in health care. Different tools and techniques have been adopted to measure and manage quality, but clinical errors are still too numerous, suggesting that traditional quality improvement systems are unable to deal appropriately with hospital challenges. The purpose of this paper is to grasp the current tools, practices, and guidelines adopted in health care to improve quality and patient safety and create a base for future research on this young subject. Methods A systematic literature review was carried out. A search of academic databases, including papers that focus not only on lean management, but also on clinical errors and risk reduction, yielded 47 papers. The general characteristics of the selected papers were analyzed, and a content analysis was conducted. Results A variety of managerial techniques, tools, and practices are being adopted in health care, and traditional methodologies have to be integrated with the latest ones in order to reduce errors and ensure high quality and patient safety. As it has been demonstrated, these tools are useful not only for achieving efficiency objectives, but also for providing higher quality and patient safety. Critical indications and guidelines for successful implementation of new health managerial methodologies are provided and synthesized in an operative scheme useful for extending and deepening knowledge of these issues with further studies. Conclusion This research contributes to introducing a new theme in health care literature regarding the development of successful projects with both clinical risk management and health lean management objectives, and should address solutions for improving health care even in the current context of decreasing resources. PMID:24307833

Uncharted territory: measuring costs of diagnostic errors outside the medical record.

PubMed

Schwartz, Alan; Weiner, Saul J; Weaver, Frances; Yudkowsky, Rachel; Sharma, Gunjan; Binns-Calvey, Amy; Preyss, Ben; Jordan, Neil

2012-11-01

In a past study using unannounced standardised patients (USPs), substantial rates of diagnostic and treatment errors were documented among internists. Because the authors know the correct disposition of these encounters and obtained the physicians' notes, they can identify necessary treatment that was not provided and unnecessary treatment. They can also discern which errors can be identified exclusively from a review of the medical records. To estimate the avoidable direct costs incurred by physicians making errors in our previous study. In the study, USPs visited 111 internal medicine attending physicians. They presented variants of four previously validated cases that jointly manipulate the presence or absence of contextual and biomedical factors that could lead to errors in management if overlooked. For example, in a patient with worsening asthma symptoms, a complicating biomedical factor was the presence of reflux disease and a complicating contextual factor was inability to afford the currently prescribed inhaler. Costs of missed or unnecessary services were computed using Medicare cost-based reimbursement data. Fourteen practice locations, including two academic clinics, two community-based primary care networks with multiple sites, a core safety net provider, and three Veteran Administration government facilities. Contribution of errors to costs of care. Overall, errors in care resulted in predicted costs of approximately $174,000 across 399 visits, of which only $8745 was discernible from a review of the medical records alone (without knowledge of the correct diagnoses). The median cost of error per visit with an incorrect care plan differed by case and by presentation variant within case. Chart reviews alone underestimate costs of care because they typically reflect appropriate treatment decisions conditional on (potentially erroneous) diagnoses. Important information about patient context is often entirely missing from medical records. Experimental methods, including the use of USPs, reveal the substantial costs of these errors.

Missed nursing care: a concept analysis.

PubMed

Kalisch, Beatrice J; Landstrom, Gay L; Hinshaw, Ada Sue

2009-07-01

This paper is a report of the analysis of the concept of missed nursing care. According to patient safety literature, missed nursing care is an error of omission. This concept has been conspicuously absent in quality and patient safety literature, with individual aspects of nursing care left undone given only occasional mention. An 8-step method of concept analysis - select concept, determine purpose, identify uses, define attributes, identify model case, describe related and contrary cases, identify antecedents and consequences and define empirical referents - was used to examine the concept of missed nursing care. The sources for the analysis were identified by systematic searches of the World Wide Web, MEDLINE, CINAHL and reference lists of related journal articles with a timeline of 1970 to April 2008. Missed nursing care, conceptualized within the Missed Nursing Care Model, is defined as any aspect of required patient care that is omitted (either in part or in whole) or delayed. Various attribute categories reported by nurses in acute care settings contribute to missed nursing care: (1) antecedents that catalyse the need for a decision about priorities; (2) elements of the nursing process and (3) internal perceptions and values of the nurse. Multiple elements in the nursing environment and internal to nurses influence whether needed nursing care is provided. Missed care as conceptualized within the Missed Care Model is a universal phenomenon. The concept is expected to occur across all cultures and countries, thus being international in scope.

Effectiveness of Specimen Collection Technology in the Reduction of Collection Turnaround Time and Mislabeled Specimens in Emergency, Medical-Surgical, Critical Care, and Maternal Child Health Departments.

PubMed

Saathoff, April M; MacDonald, Ryan; Krenzischek, Erundina

2018-03-01

The objective of this study was to evaluate the impact of specimen collection technology implementation featuring computerized provider order entry, positive patient identification, bedside specimen label printing, and barcode scanning on the reduction of mislabeled specimens and collection turnaround times in the emergency, medical-surgical, critical care, and maternal child health departments at a community teaching hospital. A quantitative analysis of a nonrandomized, pre-post intervention study design evaluated the statistical significance of reduction of mislabeled specimen percentages and collection turnaround times affected by the implementation of specimen collection technology. Mislabeled specimen percentages in all areas decreased from an average of 0.020% preimplementation to an average of 0.003% postimplementation, with a P < .001. Collection turnaround times longer than 60 minutes decreased after the implementation of specimen collection technology by an average of 27%, with a P < .001. Specimen collection and identification errors are a significant problem in healthcare, contributing to incorrect diagnoses, delayed care, lack of essential treatments, and patient injury or death. Collection errors can also contribute to an increased length of stay, increased healthcare costs, and decreased patient satisfaction. Specimen collection technology has structures in place to prevent collection errors and improve the overall efficiency of the specimen collection process.

What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature.

PubMed

Assiri, Ghadah Asaad; Shebl, Nada Atef; Mahmoud, Mansour Adam; Aloudah, Nouf; Grant, Elizabeth; Aljadhey, Hisham; Sheikh, Aziz

2018-05-05

To investigate the epidemiology of medication errors and error-related adverse events in adults in primary care, ambulatory care and patients' homes. Systematic review. Six international databases were searched for publications between 1 January 2006 and 31 December 2015. Two researchers independently extracted data from eligible studies and assessed the quality of these using established instruments. Synthesis of data was informed by an appreciation of the medicines' management process and the conceptual framework from the International Classification for Patient Safety. 60 studies met the inclusion criteria, of which 53 studies focused on medication errors, 3 on error-related adverse events and 4 on risk factors only. The prevalence of prescribing errors was reported in 46 studies: prevalence estimates ranged widely from 2% to 94%. Inappropriate prescribing was the most common type of error reported. Only one study reported the prevalence of monitoring errors, finding that incomplete therapeutic/safety laboratory-test monitoring occurred in 73% of patients. The incidence of preventable adverse drug events (ADEs) was estimated as 15/1000 person-years, the prevalence of drug-drug interaction-related adverse drug reactions as 7% and the prevalence of preventable ADE as 0.4%. A number of patient, healthcare professional and medication-related risk factors were identified, including the number of medications used by the patient, increased patient age, the number of comorbidities, use of anticoagulants, cases where more than one physician was involved in patients' care and care being provided by family physicians/general practitioners. A very wide variation in the medication error and error-related adverse events rates is reported in the studies, this reflecting heterogeneity in the populations studied, study designs employed and outcomes evaluated. This review has identified important limitations and discrepancies in the methodologies used and gaps in the literature on the epidemiology and outcomes of medication errors in community settings. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients.

PubMed

Vélez-Díaz-Pallarés, Manuel; Delgado-Silveira, Eva; Carretero-Accame, María Emilia; Bermejo-Vicedo, Teresa

2013-01-01

To identify actions to reduce medication errors in the process of drug prescription, validation and dispensing, and to evaluate the impact of their implementation. A Health Care Failure Mode and Effect Analysis (HFMEA) was supported by a before-and-after medication error study to measure the actual impact on error rate after the implementation of corrective actions in the process of drug prescription, validation and dispensing in wards equipped with computerised physician order entry (CPOE) and unit-dose distribution system (788 beds out of 1080) in a Spanish university hospital. The error study was carried out by two observers who reviewed medication orders on a daily basis to register prescription errors by physicians and validation errors by pharmacists. Drugs dispensed in the unit-dose trolleys were reviewed for dispensing errors. Error rates were expressed as the number of errors for each process divided by the total opportunities for error in that process times 100. A reduction in prescription errors was achieved by providing training for prescribers on CPOE, updating prescription procedures, improving clinical decision support and automating the software connection to the hospital census (relative risk reduction (RRR), 22.0%; 95% CI 12.1% to 31.8%). Validation errors were reduced after optimising time spent in educating pharmacy residents on patient safety, developing standardised validation procedures and improving aspects of the software's database (RRR, 19.4%; 95% CI 2.3% to 36.5%). Two actions reduced dispensing errors: reorganising the process of filling trolleys and drawing up a protocol for drug pharmacy checking before delivery (RRR, 38.5%; 95% CI 14.1% to 62.9%). HFMEA facilitated the identification of actions aimed at reducing medication errors in a healthcare setting, as the implementation of several of these led to a reduction in errors in the process of drug prescription, validation and dispensing.

Medication errors: an overview for clinicians.

PubMed

Wittich, Christopher M; Burkle, Christopher M; Lanier, William L

2014-08-01

Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for practicing physicians that focuses on medication error (1) terminology and definitions, (2) incidence, (3) risk factors, (4) avoidance strategies, and (5) disclosure and legal consequences. A medication error is any error that occurs at any point in the medication use process. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (eg, similar sounding names, low therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition, polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions and other communications, cognitive biases) can precipitate medication errors. Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. Methods to prevent medication errors from occurring (eg, use of information technology, better drug labeling, and medication reconciliation) have been used with varying success. When an error is discovered, patients expect disclosure that is timely, given in person, and accompanied with an apology and communication of efforts to prevent future errors. Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients. Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Achieving the "triple aim" for inborn errors of metabolism: a review of challenges to outcomes research and presentation of a new practice-based evidence framework.

PubMed

Potter, Beth K; Chakraborty, Pranesh; Kronick, Jonathan B; Wilson, Kumanan; Coyle, Doug; Feigenbaum, Annette; Geraghty, Michael T; Karaceper, Maria D; Little, Julian; Mhanni, Aizeddin; Mitchell, John J; Siriwardena, Komudi; Wilson, Brenda J; Syrowatka, Ania

2013-06-01

Across all areas of health care, decision makers are in pursuit of what Berwick and colleagues have called the "triple aim": improving patient experiences with care, improving health outcomes, and managing health system impacts. This is challenging in a rare disease context, as exemplified by inborn errors of metabolism. There is a need for evaluative outcomes research to support effective and appropriate care for inborn errors of metabolism. We suggest that such research should consider interventions at both the level of the health system (e.g., early detection through newborn screening, programs to provide access to treatments) and the level of individual patient care (e.g., orphan drugs, medical foods). We have developed a practice-based evidence framework to guide outcomes research for inborn errors of metabolism. Focusing on outcomes across the triple aim, this framework integrates three priority themes: tailoring care in the context of clinical heterogeneity; a shift from "urgent care" to "opportunity for improvement"; and the need to evaluate the comparative effectiveness of emerging and established therapies. Guided by the framework, a new Canadian research network has been established to generate knowledge that will inform the design and delivery of health services for patients with inborn errors of metabolism and other rare diseases.

Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework.

PubMed

Naveh, Eitan; Katz-Navon, Tal

2014-01-01

To avoid errors and improve patient safety and quality of care, health care organizations need to identify the sources of failures and facilitate implementation of corrective actions. Hence, health care organizations try to collect reports and data about errors by investing enormous resources in reporting systems. However, despite health care organizations' declared goal of increasing the voluntary reporting of errors and although the Patient Safety and Quality Improvement Act of 2005 (S.544, Public Law 109-41) legalizes efforts to secure reporters from specific liabilities, the problem of underreporting of adverse events by staff members remains. The purpose of the paper is to develop a theory-based model and a set of propositions to understand the antecedents of staff members' willingness to report errors based on a literature synthesis. The model aims to explore a complex system of considerations employees use when deciding whether to report their errors or be silent about them. The model integrates the influences of three types of organizational climates (psychological safety, psychological contracts, and safety climate) and individual perceptions of the applicability of the organization's procedures and proposes their mutual influence on willingness to report errors and, as a consequence, patient safety. The model suggests that managers should try to control and influence both the way employees perceive procedure applicability and organizational context-i.e., psychological safety, no-blame contracts, and safety climate-to increase reporting and improve patient safety.

Multiple-rule bias in the comparison of classification rules

PubMed Central

Yousefi, Mohammadmahdi R.; Hua, Jianping; Dougherty, Edward R.

2011-01-01

Motivation: There is growing discussion in the bioinformatics community concerning overoptimism of reported results. Two approaches contributing to overoptimism in classification are (i) the reporting of results on datasets for which a proposed classification rule performs well and (ii) the comparison of multiple classification rules on a single dataset that purports to show the advantage of a certain rule. Results: This article provides a careful probabilistic analysis of the second issue and the ‘multiple-rule bias’, resulting from choosing a classification rule having minimum estimated error on the dataset. It quantifies this bias corresponding to estimating the expected true error of the classification rule possessing minimum estimated error and it characterizes the bias from estimating the true comparative advantage of the chosen classification rule relative to the others by the estimated comparative advantage on the dataset. The analysis is applied to both synthetic and real data using a number of classification rules and error estimators. Availability: We have implemented in C code the synthetic data distribution model, classification rules, feature selection routines and error estimation methods. The code for multiple-rule analysis is implemented in MATLAB. The source code is available at http://gsp.tamu.edu/Publications/supplementary/yousefi11a/. Supplementary simulation results are also included. Contact: edward@ece.tamu.edu Supplementary Information: Supplementary data are available at Bioinformatics online. PMID:21546390

A concept for a visual computer interface to make error taxonomies useful at the point of primary care.

PubMed

Singh, Ranjit; Pace, Wilson; Singh, Sonjoy; Singh, Ashok; Singh, Gurdev

2007-01-01

Evidence suggests that the quality of care delivered by the healthcare industry currently falls far short of its capabilities. Whilst most patient safety and quality improvement work to date has focused on inpatient settings, some estimates suggest that outpatient settings are equally important, with up to 200,000 avoidable deaths annually in the United States of America (USA) alone. There is currently a need for improved error reporting and taxonomy systems that are useful at the point of care. This provides an opportunity to harness the benefits of computer visualisation to help structure and illustrate the 'stories' behind errors. In this paper we present a concept for a visual taxonomy of errors, based on visual models of the healthcare system at both macrosystem and microsystem levels (previously published in this journal), and describe how this could be used to create a visual database of errors. In an alphatest in a US context, we were able to code a sample of 20 errors from an existing error database using the visual taxonomy. The approach is designed to capture and disseminate patient safety information in an unambiguous format that is useful to all members of the healthcare team (including the patient) at the point of care as well as at the policy-making level.

Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol.

PubMed

Hutchinson, Alison M; Sales, Anne E; Brotto, Vanessa; Bucknall, Tracey K

2015-05-19

Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals' medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.

Failure mode and effective analysis ameliorate awareness of medical errors: a 4-year prospective observational study in critically ill children.

PubMed

Daverio, Marco; Fino, Giuliana; Luca, Brugnaro; Zaggia, Cristina; Pettenazzo, Andrea; Parpaiola, Antonella; Lago, Paola; Amigoni, Angela

2015-12-01

Errors in are estimated to occur with an incidence of 3.7-16.6% in hospitalized patients. The application of systems for detection of adverse events is becoming a widespread reality in healthcare. Incident reporting (IR) and failure mode and effective analysis (FMEA) are strategies widely used to detect errors, but no studies have combined them in the setting of a pediatric intensive care unit (PICU). The aim of our study was to describe the trend of IR in a PICU and evaluate the effect of FMEA application on the number and severity of the errors detected. With this prospective observational study, we evaluated the frequency IR documented in standard IR forms completed from January 2009 to December 2012 in the PICU of Woman's and Child's Health Department of Padova. On the basis of their severity, errors were classified as: without outcome (55%), with minor outcome (16%), with moderate outcome (10%), and with major outcome (3%); 16% of reported incidents were 'near misses'. We compared the data before and after the introduction of FMEA. Sixty-nine errors were registered, 59 (86%) concerning drug therapy (83% during prescription). Compared to 2009-2010, in 2011-2012, we noted an increase of reported errors (43 vs 26) with a reduction of their severity (21% vs 8% 'near misses' and 65% vs 38% errors with no outcome). With the introduction of FMEA, we obtained an increased awareness in error reporting. Application of these systems will improve the quality of healthcare services. © 2015 John Wiley & Sons Ltd.

An error taxonomy system for analysis of haemodialysis incidents.

PubMed

Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

2014-12-01

This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

The inference of atmospheric ozone using satellite horizon measurements in the 1042 per cm band.

NASA Technical Reports Server (NTRS)

Russell, J. M., III; Drayson, S. R.

1972-01-01

Description of a method for inferring atmospheric ozone information using infrared horizon radiance measurements in the 1042 per cm band. An analysis based on this method proves the feasibility of the horizon experiment for determining ozone information and shows that the ozone partial pressure can be determined in the altitude range from 50 down to 25 km. A comprehensive error study is conducted which considers effects of individual errors as well as the effect of all error sources acting simultaneously. The results show that in the absence of a temperature profile bias error, it should be possible to determine the ozone partial pressure to within an rms value of 15 to 20%. It may be possible to reduce this rms error to 5% by smoothing the solution profile. These results would be seriously degraded by an atmospheric temperature bias error of only 3 K; thus, great care should be taken to minimize this source of error in an experiment. It is probable, in view of recent technological developments, that these errors will be much smaller in future flight experiments and the altitude range will widen to include from about 60 km down to the tropopause region.

Application of human reliability analysis to nursing errors in hospitals.

PubMed

Inoue, Kayoko; Koizumi, Akio

2004-12-01

Adverse events in hospitals, such as in surgery, anesthesia, radiology, intensive care, internal medicine, and pharmacy, are of worldwide concern and it is important, therefore, to learn from such incidents. There are currently no appropriate tools based on state-of-the art models available for the analysis of large bodies of medical incident reports. In this study, a new model was developed to facilitate medical error analysis in combination with quantitative risk assessment. This model enables detection of the organizational factors that underlie medical errors, and the expedition of decision making in terms of necessary action. Furthermore, it determines medical tasks as module practices and uses a unique coding system to describe incidents. This coding system has seven vectors for error classification: patient category, working shift, module practice, linkage chain (error type, direct threat, and indirect threat), medication, severity, and potential hazard. Such mathematical formulation permitted us to derive two parameters: error rates for module practices and weights for the aforementioned seven elements. The error rate of each module practice was calculated by dividing the annual number of incident reports of each module practice by the annual number of the corresponding module practice. The weight of a given element was calculated by the summation of incident report error rates for an element of interest. This model was applied specifically to nursing practices in six hospitals over a year; 5,339 incident reports with a total of 63,294,144 module practices conducted were analyzed. Quality assurance (QA) of our model was introduced by checking the records of quantities of practices and reproducibility of analysis of medical incident reports. For both items, QA guaranteed legitimacy of our model. Error rates for all module practices were approximately of the order 10(-4) in all hospitals. Three major organizational factors were found to underlie medical errors: "violation of rules" with a weight of 826 x 10(-4), "failure of labor management" with a weight of 661 x 10(-4), and "defects in the standardization of nursing practices" with a weight of 495 x 10(-4).

Safe intravenous administration in pediatrics: A 5-year Pediatric Intensive Care Unit experience with smart pumps.

PubMed

Manrique-Rodríguez, S; Sánchez-Galindo, A C; Fernández-Llamazares, C M; Calvo-Calvo, M M; Carrillo-Álvarez, Á; Sanjurjo-Sáez, M

2016-10-01

To estimate the impact of smart pump implementation in a pediatric intensive care unit in terms of number and type of administration errors intercepted. Observational, prospective study carried out from January 2010 to March 2015 with syringe and great volumen infusion pumps available in the hospital. A tertiary level hospital pediatric intensive care unit. Infusions delivered with infusion pumps in all pediatric intensive care unit patients. Design of a drug library with safety limits for all intravenous drugs prescribed. Users' compliance with drug library as well as number and type of errors prevented were analyzed. Two hundred and eighty-three errors were intercepted during 62 months of study. A high risk drug was involved in 58% of prevented errors, such as adrenergic agonists and antagonists, sedatives, analgesics, neuromuscular blockers, opioids, potassium and insulin. Users' average compliance with the safety software was 84%. Smart pumps implementation has proven effective in intercepting high risk drugs programming errors. These results might be exportable to other critical care units, involving pediatric or adult patients. Interdisciplinary colaboration is key to succeed in this process. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana.

PubMed

Acheampong, Franklin; Tetteh, Ashalley Raymond; Anto, Berko Panyin

2016-12-01

This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana. This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes. Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems. This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.

Effects of extended work shifts and shift work on patient safety, productivity, and employee health.

PubMed

Keller, Simone M

2009-12-01

It is estimated 1.3 million health care errors occur each year and of those errors 48,000 to 98,000 result in the deaths of patients (Barger et al., 2006). Errors occur for a variety of reasons, including the effects of extended work hours and shift work. The need for around-the-clock staff coverage has resulted in creative ways to maintain quality patient care, keep health care errors or adverse events to a minimum, and still meet the needs of the organization. One way organizations have attempted to alleviate staff shortages is to create extended work shifts. Instead of the standard 8-hour shift, workers are now working 10, 12, 16, or more hours to provide continuous patient care. Although literature does support these staffing patterns, it cannot be denied that shifts beyond the traditional 8 hours increase staff fatigue, health care errors, and adverse events and outcomes and decrease alertness and productivity. This article includes a review of current literature on shift work, the definition of shift work, error rates and adverse outcomes related to shift work, health effects on shift workers, shift work effects on older workers, recommended optimal shift length, positive and negative effects of shift work on the shift worker, hazards associated with driving after extended shifts, and implications for occupational health nurses. Copyright 2009, SLACK Incorporated.

When bad things happen: adverse event reporting and disclosure as patient safety and risk management tools in the neonatal intensive care unit.

PubMed

Donn, Steven M; McDonnell, William M

2012-01-01

The Institute of Medicine has recommended a change in culture from "name and blame" to patient safety. This will require system redesign to identify and address errors, establish performance standards, and set safety expectations. This approach, however, is at odds with the present medical malpractice (tort) system. The current system is outcomes-based, meaning that health care providers and institutions are often sued despite providing appropriate care. Nevertheless, the focus should remain to provide the safest patient care. Effective peer review may be hindered by the present tort system. Reporting of medical errors is a key piece of peer review and education, and both anonymous reporting and confidential reporting of errors have potential disadvantages. Diagnostic and treatment errors continue to be the leading sources of allegations of malpractice in pediatrics, and the neonatal intensive care unit is uniquely vulnerable. Most errors result from systems failures rather than human error. Risk management can be an effective process to identify, evaluate, and address problems that may injure patients, lead to malpractice claims, and result in financial losses. Risk management identifies risk or potential risk, calculates the probability of an adverse event arising from a risk, estimates the impact of the adverse event, and attempts to control the risk. Implementation of a successful risk management program requires a positive attitude, sufficient knowledge base, and a commitment to improvement. Transparency in the disclosure of medical errors and a strategy of prospective risk management in dealing with medical errors may result in a substantial reduction in medical malpractice lawsuits, lower litigation costs, and a more safety-conscious environment. Thieme Medical Publishers, Inc.

Evaluate the ability of clinical decision support systems (CDSSs) to improve clinical practice.

PubMed

Ajami, Sima; Amini, Fatemeh

2013-01-01

Prevalence of new diseases, medical science promotion and increase of referring to health care centers, provide a good situation for medical errors growth. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. Medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes. According to the Institute of Medicine (IOM), 98,000 people die every year from preventable medical errors. In 2010 from all referred medical error records to Iran Legal Medicine Organization, 46/5% physician and medical team members were known as delinquent. One of new technologies that can reduce medical errors is clinical decision support systems (CDSSs). This study was unsystematic-review study. The literature was searched on evaluate the "ability of clinical decision support systems to improve clinical practice" with the help of library, books, conference proceedings, data bank, and also searches engines available at Google, Google scholar. For our searches, we employed the following keywords and their combinations: medical error, clinical decision support systems, Computer-Based Clinical Decision Support Systems, information technology, information system, health care quality, computer systems in the searching areas of title, keywords, abstract, and full text. In this study, more than 100 articles and reports were collected and 38 of them were selected based on their relevancy. The CDSSs are computer programs, designed for help to health care careers. These systems as a knowledge-based tool could help health care manager in analyze evaluation, improvement and selection of effective solutions in clinical decisions. Therefore, it has a main role in medical errors reduction. The aim of this study was to express ability of the CDSSs to improve

Hydrological modelling of the Chaohe Basin in China: Statistical model formulation and Bayesian inference

NASA Astrophysics Data System (ADS)

Yang, Jing; Reichert, Peter; Abbaspour, Karim C.; Yang, Hong

2007-07-01

SummaryCalibration of hydrologic models is very difficult because of measurement errors in input and response, errors in model structure, and the large number of non-identifiable parameters of distributed models. The difficulties even increase in arid regions with high seasonal variation of precipitation, where the modelled residuals often exhibit high heteroscedasticity and autocorrelation. On the other hand, support of water management by hydrologic models is important in arid regions, particularly if there is increasing water demand due to urbanization. The use and assessment of model results for this purpose require a careful calibration and uncertainty analysis. Extending earlier work in this field, we developed a procedure to overcome (i) the problem of non-identifiability of distributed parameters by introducing aggregate parameters and using Bayesian inference, (ii) the problem of heteroscedasticity of errors by combining a Box-Cox transformation of results and data with seasonally dependent error variances, (iii) the problems of autocorrelated errors, missing data and outlier omission with a continuous-time autoregressive error model, and (iv) the problem of the seasonal variation of error correlations with seasonally dependent characteristic correlation times. The technique was tested with the calibration of the hydrologic sub-model of the Soil and Water Assessment Tool (SWAT) in the Chaohe Basin in North China. The results demonstrated the good performance of this approach to uncertainty analysis, particularly with respect to the fulfilment of statistical assumptions of the error model. A comparison with an independent error model and with error models that only considered a subset of the suggested techniques clearly showed the superiority of the approach based on all the features (i)-(iv) mentioned above.

[The experience of implementation of system of quality management in the Department of Laboratory Diagnostic of the N.V. Sklifosofskiy Research Institute of Emergency Care of Moscow Health Department: a lecture].

PubMed

Zenina, L P; Godkov, M A

2013-08-01

The article presents the experience of implementation of system of quality management into the practice of multi-field laboratory of emergency medical care hospital. The analysis of laboratory errors is applied and the modes of their prevention are demonstrated. The ratings of department of laboratory diagnostic of the N. V. Sklifosofskiy research institute of emergency care in the program EQAS (USA) Monthly Clinical Chemistry from 2007 are presented. The implementation of the system of quality management of laboratory analysis into department of laboratory diagnostic made it possible to support physicians of clinical departments with reliable information. The confidence of clinicians to received results increased. The effectiveness of laboratory diagnostic increased due to lowering costs of analysis without negative impact to quality of curative process.

Influence of an independent quarterly audit on publicly reported vancomycin-resistant enterocococi bacteremia data in Ontario, Canada.

PubMed

Prematunge, Chatura; Policarpio, Michelle E; Johnstone, Jennie; Adomako, Kwaku; Nadolny, Emily; Lam, Freda; Li, Ye; Brown, Kevin A; Garber, Gary

2018-04-13

All Ontario hospitals are mandated to self-report vancomycin-resistant enterocococi (VRE) bacteremias to Ontario's Ministry of Health and Long-term Care for public reporting purposes. Independent quarterly audits of publicly reported VRE bacteremias between September 2013 and June 2015 were carried out by Public Health Ontario. VRE bacteremia case-reporting errors between January 2009 and August 2013 were identified by a single retrospective audit. Employing a quasiexperimental pre-post study design, the relative risk of VRE bacteremia reporting errors before and after quarterly audits were modeled using Poisson regression adjusting for hospital type, case counts reported to the Ministry of Health and Long-term Care, and autocorrelation via generalized estimating equation. Overall, 24.5% (126 out of 514) of VRE bacteremias were reported in error; 114 out of 367 (31%) VRE bacteremias reported before quarterly audits and 12 out of 147 (8.1%) reported after audits were found to be incorrect. In adjusted analysis, quarterly audits of VRE bacteremias were associated with significant reductions in reporting errors when compared with before quarterly auditing (relative risk, 0.17; 95% confidence interval, 0.05-0.63). Risk of reporting errors among community hospitals were greater than acute teaching hospitals of the region (relative risk, 4.39; 95% CI, 3.07-5.70). This study found independent quarterly audits of publicly reported VRE bacteremias to be associated with significant reductions in reporting errors. Public reporting systems should consider adopting routine data audits and hospital-targeted training to improve data accuracy. Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.

ISMP Medication Error Report Analysis

PubMed Central

Cohen, Michael R.; Smetzer, Judy L.

2017-01-01

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications. PMID:28179735

ISMP Medication Error Report Analysis

PubMed Central

Cohen, Michael R.; Smetzer, Judy L.

2017-01-01

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your in-service training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers’ names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters’ wishes as to the level of detail included in publications. PMID:29276260

ISMP Medication Error Report Analysis

PubMed Central

Cohen, Michael R.; Smetzer, Judy L.

2016-01-01

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications. PMID:28057945

ISMP Medication Error Report Analysis

PubMed Central

Cohen, Michael R.; Smetzer, Judy L.

2016-01-01

ABSTRACT These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural-safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were receivedthrough the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications. PMID:27928183

[Improving the continuous care process in primary care during weekends and holidays: redesigning and FMEA].

PubMed

Cañada Dorado, A; Cárdenas Valladolid, J; Espejo Matorrales, F; García Ferradal, I; Sastre Páez, S; Vicente Martín, I

2010-01-01

To describe a project carried out in order to improve the process of Continuous Health Care (CHC) on Saturdays and bank holidays in Primary Care, area number 4, Madrid. The aim of this project was to guarantee a safe and error-free service to patients receiving home health care on weekends. The urgent need for improving CHC process was identified by the Risk Management Functional Unit (RMFU) of the area. In addition, some complaints had been received from the nurses involved in the process as well as from their patients. A SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis performed in 2009 highlighted a number of problems with the process. As a result, a project for improvement was drawn up, to be implemented in the following stages: 1. Redesigning and improving the existing process. 2. Application of failure mode and effect analysis (FMEA) to the new process. 3. Follow up, managing and leading the project. 4. Nurse training. 5. Implementing the process in the whole area. 6. CHC nurse satisfaction surveys. After carrying out this project, the efficiency and level of automation improved considerably. Since implementation of the process enhancement measures, no complaints have been received from patients and surveys show that CHC nurse satisfaction has improved. By using FMEA, errors were given priority and enhancement steps were taken in order to: Inform professionals, back-up personnel and patients about the process. Improve the specialist follow-up report. Provide training in ulcer patient care. The process enhancement, and especially its automation, has resulted in a significant step forward toward achieving greater patient safety. FMEA was a useful tool, which helped in taking some important actions. Finally, CHC nurse satisfaction has clearly improved. Copyright © 2009 SECA. Published by Elsevier Espana. All rights reserved.

Disclosure of Medical Errors in Oman

PubMed Central

Norrish, Mark I. K.

2015-01-01

Objectives: This study aimed to provide insight into the preferences for and perceptions of medical error disclosure (MED) by members of the public in Oman. Methods: Between January and June 2012, an online survey was used to collect responses from 205 members of the public across five governorates of Oman. Results: A disclosure gap was revealed between the respondents’ preferences for MED and perceived current MED practices in Oman. This disclosure gap extended to both the type of error and the person most likely to disclose the error. Errors resulting in patient harm were found to have a strong influence on individuals’ perceived quality of care. In addition, full disclosure was found to be highly valued by respondents and able to mitigate for a perceived lack of care in cases where medical errors led to damages. Conclusion: The perceived disclosure gap between respondents’ MED preferences and perceptions of current MED practices in Oman needs to be addressed in order to increase public confidence in the national health care system. PMID:26052463

[Surveillance of health care errors. An overview of the published data in Argentina].

PubMed

Codermatz, Marcela A; Trillo, Carolina; Berenstein, Graciela; Ortiz, Zulma

2006-01-01

In the last decades, public health surveillance extended its scope of study to new fields, such as medical errors, in order to improve patient safety. This study was aimed to review all the evidence produced in Argentina about the surveillance of medical errors. An exhaustive literature search was performed. A total of 4656 abstracts were assessed (150 MEDLINE, 145 LILACS, and 4361 hand searched abstracts). Of them, 52 were analysed and 8 were considered relevant for health care error surveillance. Different approaches were used to study medical errors. Some of them have focused on patient safety and others on medical malpractice. There is still a need to improve the surveillance of this type of event. Mainly, the quality reports of study design and surveillance attributes were unclear. A critical appraisal and synthesis of all relevant studies on health care errors may help to understand not only the state of the art, but also to define research priorities.

Eliciting the Functional Processes of Apologizing for Errors in Health Care

PubMed Central

Prothero, Marie M.; Morse, Janice M.

2017-01-01

The purpose of this article was to analyze the concept development of apology in the context of errors in health care, the administrative response, policy and format/process of the subsequent apology. Using pragmatic utility and a systematic review of the literature, 29 articles and one book provided attributes involved in apologizing. Analytic questions were developed to guide the data synthesis and types of apologies used in different circumstances identified. The antecedents of apologizing, and the attributes and outcomes were identified. A model was constructed illustrating the components of a complete apology, other types of apologies, and ramifications/outcomes of each. Clinical implications of developing formal policies for correcting medical errors through apologies are recommended. Defining the essential elements of apology is the first step in establishing a just culture in health care. Respect for patient-centered care reduces the retaliate consequences following an error, and may even restore the physician patient relationship. PMID:28540337

A description of medication errors reported by pharmacists in a neonatal intensive care unit.

PubMed

Pawluk, Shane; Jaam, Myriam; Hazi, Fatima; Al Hail, Moza Sulaiman; El Kassem, Wessam; Khalifa, Hanan; Thomas, Binny; Abdul Rouf, Pallivalappila

2017-02-01

Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.

Nano-metrology: The art of measuring X-ray mirrors with slope errors <100 nrad

DOE Office of Scientific and Technical Information (OSTI.GOV)

Alcock, Simon G., E-mail: simon.alcock@diamond.ac.uk; Nistea, Ioana; Sawhney, Kawal

2016-05-15

We present a comprehensive investigation of the systematic and random errors of the nano-metrology instruments used to characterize synchrotron X-ray optics at Diamond Light Source. With experimental skill and careful analysis, we show that these instruments used in combination are capable of measuring state-of-the-art X-ray mirrors. Examples are provided of how Diamond metrology data have helped to achieve slope errors of <100 nrad for optical systems installed on synchrotron beamlines, including: iterative correction of substrates using ion beam figuring and optimal clamping of monochromator grating blanks in their holders. Simulations demonstrate how random noise from the Diamond-NOM’s autocollimator adds intomore » the overall measured value of the mirror’s slope error, and thus predict how many averaged scans are required to accurately characterize different grades of mirror.« less

The Gnomon Experiment

NASA Astrophysics Data System (ADS)

Krisciunas, Kevin

2007-12-01

A gnomon, or vertical pointed stick, can be used to determine the north-south direction at a site, as well as one's latitude. If one has accurate time and knows one's time zone, it is also possible to determine one's longitude. From observations on the first day of winter and the first day of summer one can determine the obliquity of the ecliptic. Since we can obtain accurate geographical coordinates from Google Earth or a GPS device, analysis of set of shadow length measurements can be used by students to learn about astronomical coordinate systems, time systems, systematic errors, and random errors. Systematic latitude errors of student datasets are typically 30 nautical miles (0.5 degree) or more, but with care one can achieve systematic and random errors less than 8 nautical miles. One of the advantages of this experiment is that it can be carried out during the day. Also, it is possible to determine if a student has made up his data.

Errors in laboratory medicine: practical lessons to improve patient safety.

PubMed

Howanitz, Peter J

2005-10-01

Patient safety is influenced by the frequency and seriousness of errors that occur in the health care system. Error rates in laboratory practices are collected routinely for a variety of performance measures in all clinical pathology laboratories in the United States, but a list of critical performance measures has not yet been recommended. The most extensive databases describing error rates in pathology were developed and are maintained by the College of American Pathologists (CAP). These databases include the CAP's Q-Probes and Q-Tracks programs, which provide information on error rates from more than 130 interlaboratory studies. To define critical performance measures in laboratory medicine, describe error rates of these measures, and provide suggestions to decrease these errors, thereby ultimately improving patient safety. A review of experiences from Q-Probes and Q-Tracks studies supplemented with other studies cited in the literature. Q-Probes studies are carried out as time-limited studies lasting 1 to 4 months and have been conducted since 1989. In contrast, Q-Tracks investigations are ongoing studies performed on a yearly basis and have been conducted only since 1998. Participants from institutions throughout the world simultaneously conducted these studies according to specified scientific designs. The CAP has collected and summarized data for participants about these performance measures, including the significance of errors, the magnitude of error rates, tactics for error reduction, and willingness to implement each of these performance measures. A list of recommended performance measures, the frequency of errors when these performance measures were studied, and suggestions to improve patient safety by reducing these errors. Error rates for preanalytic and postanalytic performance measures were higher than for analytic measures. Eight performance measures were identified, including customer satisfaction, test turnaround times, patient identification, specimen acceptability, proficiency testing, critical value reporting, blood product wastage, and blood culture contamination. Error rate benchmarks for these performance measures were cited and recommendations for improving patient safety presented. Not only has each of the 8 performance measures proven practical, useful, and important for patient care, taken together, they also fulfill regulatory requirements. All laboratories should consider implementing these performance measures and standardizing their own scientific designs, data analysis, and error reduction strategies according to findings from these published studies.

Patient safety priorities in mental healthcare in Switzerland: a modified Delphi study.

PubMed

Mascherek, Anna C; Schwappach, David L B

2016-08-05

Identifying patient safety priorities in mental healthcare is an emerging issue. A variety of aspects of patient safety in medical care apply for patient safety in mental care as well. However, specific aspects may be different as a consequence of special characteristics of patients, setting and treatment. The aim of the present study was to combine knowledge from the field and research and bundle existing initiatives and projects to define patient safety priorities in mental healthcare in Switzerland. The present study draws on national expert panels, namely, round-table discussion and modified Delphi consensus method. As preparation for the modified Delphi questionnaire, two round-table discussions and one semistructured questionnaire were conducted. Preparative work was conducted between May 2015 and October 2015. The modified Delphi was conducted to gauge experts' opinion on priorities in patient safety in mental healthcare in Switzerland. In two independent rating rounds, experts made private ratings. The modified Delphi was conducted in winter 2015. Nine topics were defined along the treatment pathway: diagnostic errors, non-drug treatment errors, medication errors, errors related to coercive measures, errors related to aggression management against self and others, errors in treatment of suicidal patients, communication errors, errors at interfaces of care and structural errors. Patient safety is considered as an important topic of quality in mental healthcare among experts, but it has been seriously neglected up until now. Activities in research and in practice are needed. Structural errors and diagnostics were given highest priority. From the topics identified, some are overlapping with important aspects of patient safety in medical care; however, some core aspects are unique. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Patient safety priorities in mental healthcare in Switzerland: a modified Delphi study

PubMed Central

Mascherek, Anna C

2016-01-01

Objective Identifying patient safety priorities in mental healthcare is an emerging issue. A variety of aspects of patient safety in medical care apply for patient safety in mental care as well. However, specific aspects may be different as a consequence of special characteristics of patients, setting and treatment. The aim of the present study was to combine knowledge from the field and research and bundle existing initiatives and projects to define patient safety priorities in mental healthcare in Switzerland. The present study draws on national expert panels, namely, round-table discussion and modified Delphi consensus method. Design As preparation for the modified Delphi questionnaire, two round-table discussions and one semistructured questionnaire were conducted. Preparative work was conducted between May 2015 and October 2015. The modified Delphi was conducted to gauge experts' opinion on priorities in patient safety in mental healthcare in Switzerland. In two independent rating rounds, experts made private ratings. The modified Delphi was conducted in winter 2015. Results Nine topics were defined along the treatment pathway: diagnostic errors, non-drug treatment errors, medication errors, errors related to coercive measures, errors related to aggression management against self and others, errors in treatment of suicidal patients, communication errors, errors at interfaces of care and structural errors. Conclusions Patient safety is considered as an important topic of quality in mental healthcare among experts, but it has been seriously neglected up until now. Activities in research and in practice are needed. Structural errors and diagnostics were given highest priority. From the topics identified, some are overlapping with important aspects of patient safety in medical care; however, some core aspects are unique. PMID:27496233

Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms.

PubMed

Fox, Michael D; Bump, Gregory M; Butler, Gabriella A; Chen, Ling-Wan; Buchert, Andrew R

2017-01-30

Reporting medical errors is a focus of the patient safety movement. As frontline physicians, residents are optimally positioned to recognize errors and flaws in systems of care. Previous work highlights the difficulty of engaging residents in identification and/or reduction of medical errors and in integrating these trainees into their institutions' cultures of safety. The authors describe the implementation of a longitudinal, discipline-based, multifaceted curriculum to enhance the reporting of errors by pediatric residents at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center. The key elements of this curriculum included providing the necessary education to identify medical errors with an emphasis on systems-based causes, modeling of error reporting by faculty, and integrating error reporting and discussion into the residents' daily activities. The authors tracked monthly error reporting rates by residents and other health care professionals, in addition to serious harm event rates at the institution. The interventions resulted in significant increases in error reports filed by residents, from 3.6 to 37.8 per month over 4 years (P < 0.0001). This increase in resident error reporting correlated with a decline in serious harm events, from 15.0 to 8.1 per month over 4 years (P = 0.01). Integrating patient safety into the everyday resident responsibilities encourages frequent reporting and discussion of medical errors and leads to improvements in patient care. Multiple simultaneous interventions are essential to making residents part of the safety culture of their training hospitals.

An Empirically Derived Taxonomy of Factors Affecting Physicians' Willingness to Disclose Medical Errors

PubMed Central

Kaldjian, Lauris C; Jones, Elizabeth W; Rosenthal, Gary E; Tripp-Reimer, Toni; Hillis, Stephen L

2006-01-01

BACKGROUND Physician disclosure of medical errors to institutions, patients, and colleagues is important for patient safety, patient care, and professional education. However, the variables that may facilitate or impede disclosure are diverse and lack conceptual organization. OBJECTIVE To develop an empirically derived, comprehensive taxonomy of factors that affects voluntary disclosure of errors by physicians. DESIGN A mixed-methods study using qualitative data collection (structured literature search and exploratory focus groups), quantitative data transformation (sorting and hierarchical cluster analysis), and validation procedures (confirmatory focus groups and expert review). RESULTS Full-text review of 316 articles identified 91 impeding or facilitating factors affecting physicians' willingness to disclose errors. Exploratory focus groups identified an additional 27 factors. Sorting and hierarchical cluster analysis organized factors into 8 domains. Confirmatory focus groups and expert review relocated 6 factors, removed 2 factors, and modified 4 domain names. The final taxonomy contained 4 domains of facilitating factors (responsibility to patient, responsibility to self, responsibility to profession, responsibility to community), and 4 domains of impeding factors (attitudinal barriers, uncertainties, helplessness, fears and anxieties). CONCLUSIONS A taxonomy of facilitating and impeding factors provides a conceptual framework for a complex field of variables that affects physicians' willingness to disclose errors to institutions, patients, and colleagues. This taxonomy can be used to guide the design of studies to measure the impact of different factors on disclosure, to assist in the design of error-reporting systems, and to inform educational interventions to promote the disclosure of errors to patients. PMID:16918739

Predictors and Outcomes of Burnout in Primary Care Physicians.

PubMed

Rabatin, Joseph; Williams, Eric; Baier Manwell, Linda; Schwartz, Mark D; Brown, Roger L; Linzer, Mark

2016-01-01

To assess relationships between primary care work conditions, physician burnout, quality of care, and medical errors. Cross-sectional and longitudinal analyses of data from the MEMO (Minimizing Error, Maximizing Outcome) Study. Two surveys of 422 family physicians and general internists, administered 1 year apart, queried physician job satisfaction, stress and burnout, organizational culture, and intent to leave within 2 years. A chart audit of 1795 of their adult patients with diabetes and/or hypertension assessed care quality and medical errors. Women physicians were almost twice as likely as men to report burnout (36% vs 19%, P < .001). Burned out clinicians reported less satisfaction (P < .001), more job stress (P < .001), more time pressure during visits (P < .01), more chaotic work conditions (P < .001), and less work control (P < .001). Their workplaces were less likely to emphasize work-life balance (P < .001) and they noted more intent to leave the practice (56% vs 21%, P < .001). There were no consistent relationships between burnout, care quality, and medical errors. Burnout is highly associated with adverse work conditions and a greater intention to leave the practice, but not with adverse patient outcomes. Care quality thus appears to be preserved at great personal cost to primary care physicians. Efforts focused on workplace redesign and physician self-care are warranted to sustain the primary care workforce. © The Author(s) 2015.

Predictors and Outcomes of Burnout in Primary Care Physicians

PubMed Central

Rabatin, Joseph; Williams, Eric; Baier Manwell, Linda; Schwartz, Mark D.; Brown, Roger L.; Linzer, Mark

2015-01-01

Objective: To assess relationships between primary care work conditions, physician burnout, quality of care, and medical errors. Methods: Cross-sectional and longitudinal analyses of data from the MEMO (Minimizing Error, Maximizing Outcome) Study. Two surveys of 422 family physicians and general internists, administered 1 year apart, queried physician job satisfaction, stress and burnout, organizational culture, and intent to leave within 2 years. A chart audit of 1795 of their adult patients with diabetes and/or hypertension assessed care quality and medical errors. Key Results: Women physicians were almost twice as likely as men to report burnout (36% vs 19%, P < .001). Burned out clinicians reported less satisfaction (P < .001), more job stress (P < .001), more time pressure during visits (P < .01), more chaotic work conditions (P < .001), and less work control (P < .001). Their workplaces were less likely to emphasize work-life balance (P < .001) and they noted more intent to leave the practice (56% vs 21%, P < .001). There were no consistent relationships between burnout, care quality, and medical errors. Conclusions: Burnout is highly associated with adverse work conditions and a greater intention to leave the practice, but not with adverse patient outcomes. Care quality thus appears to be preserved at great personal cost to primary care physicians. Efforts focused on workplace redesign and physician self-care are warranted to sustain the primary care workforce. PMID:26416697

How do Community Pharmacies Recover from E-prescription Errors?

PubMed Central

Odukoya, Olufunmilola K.; Stone, Jamie A.; Chui, Michelle A.

2014-01-01

Background The use of e-prescribing is increasing annually, with over 788 million e-prescriptions received in US pharmacies in 2012. Approximately 9% of e-prescriptions have medication errors. Objective To describe the process used by community pharmacy staff to detect, explain, and correct e-prescription errors. Methods The error recovery conceptual framework was employed for data collection and analysis. 13 pharmacists and 14 technicians from five community pharmacies in Wisconsin participated in the study. A combination of data collection methods were utilized, including direct observations, interviews, and focus groups. The transcription and content analysis of recordings were guided by the three-step error recovery model. Results Most of the e-prescription errors were detected during the entering of information into the pharmacy system. These errors were detected by both pharmacists and technicians using a variety of strategies which included: (1) performing double checks of e-prescription information; (2) printing the e-prescription to paper and confirming the information on the computer screen with information from the paper printout; and (3) using colored pens to highlight important information. Strategies used for explaining errors included: (1) careful review of patient’ medication history; (2) pharmacist consultation with patients; (3) consultation with another pharmacy team member; and (4) use of online resources. In order to correct e-prescription errors, participants made educated guesses of the prescriber’s intent or contacted the prescriber via telephone or fax. When e-prescription errors were encountered in the community pharmacies, the primary goal of participants was to get the order right for patients by verifying the prescriber’s intent. Conclusion Pharmacists and technicians play an important role in preventing e-prescription errors through the detection of errors and the verification of prescribers’ intent. Future studies are needed to examine factors that facilitate or hinder recovery from e-prescription errors. PMID:24373898

The use of a contextual, modal and psychological classification of medication errors in the emergency department: a retrospective descriptive study.

PubMed

Cabilan, C J; Hughes, James A; Shannon, Carl

2017-12-01

To describe the contextual, modal and psychological classification of medication errors in the emergency department to know the factors associated with the reported medication errors. The causes of medication errors are unique in every clinical setting; hence, error minimisation strategies are not always effective. For this reason, it is fundamental to understand the causes specific to the emergency department so that targeted strategies can be implemented. Retrospective analysis of reported medication errors in the emergency department. All voluntarily staff-reported medication-related incidents from 2010-2015 from the hospital's electronic incident management system were retrieved for analysis. Contextual classification involved the time, place and the type of medications involved. Modal classification pertained to the stage and issue (e.g. wrong medication, wrong patient). Psychological classification categorised the errors in planning (knowledge-based and rule-based errors) and skill (slips and lapses). There were 405 errors reported. Most errors occurred in the acute care area, short-stay unit and resuscitation area, during the busiest shifts (0800-1559, 1600-2259). Half of the errors involved high-alert medications. Many of the errors occurred during administration (62·7%), prescribing (28·6%) and commonly during both stages (18·5%). Wrong dose, wrong medication and omission were the issues that dominated. Knowledge-based errors characterised the errors that occurred in prescribing and administration. The highest proportion of slips (79·5%) and lapses (76·1%) occurred during medication administration. It is likely that some of the errors occurred due to the lack of adherence to safety protocols. Technology such as computerised prescribing, barcode medication administration and reminder systems could potentially decrease the medication errors in the emergency department. There was a possibility that some of the errors could be prevented if safety protocols were adhered to, which highlights the need to also address clinicians' attitudes towards safety. Technology can be implemented to help minimise errors in the ED, but this must be coupled with efforts to enhance the culture of safety. © 2017 John Wiley & Sons Ltd.

Evaluation of trauma care using TRISS method: the role of adjusted misclassification rate and adjusted w-statistic.

PubMed

Llullaku, Sadik S; Hyseni, Nexhmi Sh; Bytyçi, Cen I; Rexhepi, Sylejman K

2009-01-15

Major trauma is a leading cause of death worldwide. Evaluation of trauma care using Trauma Injury and Injury Severity Score (TRISS) method is focused in trauma outcome (deaths and survivors). For testing TRISS method TRISS misclassification rate is used. Calculating w-statistic, as a difference between observed and TRISS expected survivors, we compare our trauma care results with the TRISS standard. The aim of this study is to analyze interaction between misclassification rate and w-statistic and to adjust these parameters to be closer to the truth. Analysis of components of TRISS misclassification rate and w-statistic and actual trauma outcome. The component of false negative (FN) (by TRISS method unexpected deaths) has two parts: preventable (Pd) and non-preventable (nonPd) trauma deaths. Pd represents inappropriate trauma care of an institution; otherwise nonpreventable trauma deaths represents errors in TRISS method. Removing patients with preventable trauma deaths we get an Adjusted misclassification rate: (FP + FN - Pd)/N or (b+c-Pd)/N. Substracting nonPd from FN value in w-statistic formula we get an Adjusted w-statistic: [FP-(FN - nonPd)]/N, respectively (FP-Pd)/N, or (b-Pd)/N). Because adjusted formulas clean method from inappropriate trauma care, and clean trauma care from the methods error, TRISS adjusted misclassification rate and adjusted w-statistic gives more realistic results and may be used in researches of trauma outcome.

Safe Practices for Copy and Paste in the EHR

PubMed Central

Lehmann, Christoph U.; Michel, Jeremy; Solomon, Ronni; Possanza, Lorraine; Gandhi, Tejal

2017-01-01

Summary Background Copy and paste functionality can support efficiency during clinical documentation, but may promote inaccurate documentation with risks for patient safety. The Partnership for Health IT Patient Safety was formed to gather data, conduct analysis, educate, and disseminate safe practices for safer care using health information technology (IT). Objective To characterize copy and paste events in clinical care, identify safety risks, describe existing evidence, and develop implementable practice recommendations for safe reuse of information via copy and paste. Methods The Partnership 1) reviewed 12 reported safety events, 2) solicited expert input, and 3) performed a systematic literature review (2010 to January 2015) to identify publications addressing frequency, perceptions/attitudes, patient safety risks, existing guidance, and potential interventions and mitigation practices. Results The literature review identified 51 publications that were included. Overall, 66% to 90% of clinicians routinely use copy and paste. One study of diagnostic errors found that copy and paste led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care. Copy and paste can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart. Existing guidance identified specific responsibilities for authors, organizations, and electronic health record (EHR) developers. Analysis of 12 reported copy and paste safety events was congruent with problems identified from the literature review. Conclusion Despite regular copy and paste use, evidence regarding direct risk to patient safety remains sparse, with significant study limitations. Drawing on existing evidence, the Partnership developed four safe practice recommendations: 1) Provide a mechanism to make copy and paste material easily identifiable; 2) Ensure the provenance of copy and paste material is readily available; 3) Ensure adequate staff training and education; 4) Ensure copy and paste practices are regularly monitored, measured, and assessed. PMID:28074211

Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration.

PubMed

Tsou, Amy Y; Lehmann, Christoph U; Michel, Jeremy; Solomon, Ronni; Possanza, Lorraine; Gandhi, Tejal

2017-01-11

Copy and paste functionality can support efficiency during clinical documentation, but may promote inaccurate documentation with risks for patient safety. The Partnership for Health IT Patient Safety was formed to gather data, conduct analysis, educate, and disseminate safe practices for safer care using health information technology (IT). To characterize copy and paste events in clinical care, identify safety risks, describe existing evidence, and develop implementable practice recommendations for safe reuse of information via copy and paste. The Partnership 1) reviewed 12 reported safety events, 2) solicited expert input, and 3) performed a systematic literature review (2010 to January 2015) to identify publications addressing frequency, perceptions/attitudes, patient safety risks, existing guidance, and potential interventions and mitigation practices. The literature review identified 51 publications that were included. Overall, 66% to 90% of clinicians routinely use copy and paste. One study of diagnostic errors found that copy and paste led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care. Copy and paste can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart. Existing guidance identified specific responsibilities for authors, organizations, and electronic health record (EHR) developers. Analysis of 12 reported copy and paste safety events was congruent with problems identified from the literature review. Despite regular copy and paste use, evidence regarding direct risk to patient safety remains sparse, with significant study limitations. Drawing on existing evidence, the Partnership developed four safe practice recommendations: 1) Provide a mechanism to make copy and paste material easily identifiable; 2) Ensure the provenance of copy and paste material is readily available; 3) Ensure adequate staff training and education; 4) Ensure copy and paste practices are regularly monitored, measured, and assessed.

Cancer Care Coordination: a Systematic Review and Meta-Analysis of Over 30 Years of Empirical Studies.

PubMed

Gorin, Sherri Sheinfeld; Haggstrom, David; Han, Paul K J; Fairfield, Kathleen M; Krebs, Paul; Clauser, Steven B

2017-08-01

According to a landmark study by the Institute of Medicine, patients with cancer often receive poorly coordinated care in multiple settings from many providers. Lack of coordination is associated with poor symptom control, medical errors, and higher costs. The aims of this systematic review and meta-analysis were to (1) synthesize the findings of studies addressing cancer care coordination, (2) describe study outcomes across the cancer continuum, and (3) obtain a quantitative estimate of the effect of interventions in cancer care coordination on service system processes and patient health outcomes. Of 1241 abstracts identified through MEDLINE, EMBASE, CINAHL, and the Cochrane Library, 52 studies met the inclusion criteria. Each study had US or Canadian participants, comparison or control groups, measures, times, samples, and/or interventions. Two researchers independently applied a standardized search strategy, coding scheme, and online coding program to each study. Eleven studies met the additional criteria for the meta-analysis; a random effects estimation model was used for data analysis. Cancer care coordination approaches led to improvements in 81 % of outcomes, including screening, measures of patient experience with care, and quality of end-of-life care. Across the continuum of cancer care, patient navigation was the most frequent care coordination intervention, followed by home telehealth; nurse case management was third in frequency. The meta-analysis of a subset of the reviewed studies showed that the odds of appropriate health care utilization in cancer care coordination interventions were almost twice (OR = 1.9, 95 % CI = 1.5-3.5) that of comparison interventions. This review offers promising findings on the impact of cancer care coordination on increasing value and reducing healthcare costs in the USA.

Ready-to-use pre-filled syringes of atropine for anaesthesia care in French hospitals - a budget impact analysis.

PubMed

Benhamou, Dan; Piriou, Vincent; De Vaumas, Cyrille; Albaladejo, Pierre; Malinovsky, Jean-Marc; Doz, Marianne; Lafuma, Antoine; Bouaziz, Hervé

2017-04-01

Patient safety is improved by the use of labelled, ready-to-use, pre-filled syringes (PFS) when compared to conventional methods of syringe preparation (CMP) of the same product from an ampoule. However, the PFS presentation costs more than the CMP presentation. To estimate the budget impact for French hospitals of switching from atropine in ampoules to atropine PFS for anaesthesia care. A model was constructed to simulate the financial consequences of the use of atropine PFS in operating theatres, taking into account wastage and medication errors. The model tested different scenarios and a sensitivity analysis was performed. In a reference scenario, the systematic use of atropine PFS rather than atropine CMP yielded a net one-year budget saving of €5,255,304. Medication errors outweighed other cost factors relating to the use of atropine CMP (€9,425,448). Avoidance of wastage in the case of atropine CMP (prepared and unused) was a major source of savings (€1,167,323). Significant savings were made by means of other scenarios examined. The sensitivity analysis suggests that the results obtained are robust and stable for a range of parameter estimates and assumptions. The financial model was based on data obtained from the literature and expert opinions. The budget impact analysis shows that even though atropine PFS is more expensive than atropine CMP, its use would lead to significant cost savings. Savings would mainly be due to fewer medication errors and their associated consequences and the absence of wastage when atropine syringes are prepared in advance. Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

On the Need for Quantitative Bias Analysis in the Peer-Review Process.

PubMed

Fox, Matthew P; Lash, Timothy L

2017-05-15

Peer review is central to the process through which epidemiologists generate evidence to inform public health and medical interventions. Reviewers thereby act as critical gatekeepers to high-quality research. They are asked to carefully consider the validity of the proposed work or research findings by paying careful attention to the methodology and critiquing the importance of the insight gained. However, although many have noted problems with the peer-review system for both manuscripts and grant submissions, few solutions have been proposed to improve the process. Quantitative bias analysis encompasses all methods used to quantify the impact of systematic error on estimates of effect in epidemiologic research. Reviewers who insist that quantitative bias analysis be incorporated into the design, conduct, presentation, and interpretation of epidemiologic research could substantially strengthen the process. In the present commentary, we demonstrate how quantitative bias analysis can be used by investigators and authors, reviewers, funding agencies, and editors. By utilizing quantitative bias analysis in the peer-review process, editors can potentially avoid unnecessary rejections, identify key areas for improvement, and improve discussion sections by shifting from speculation on the impact of sources of error to quantification of the impact those sources of bias may have had. © The Author 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

PubMed

Hatcher, Irene; Sullivan, Mark; Hutchinson, James; Thurman, Susan; Gaffney, F Andrew

2004-10-01

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

[Why is it necessary to review the December 15th 2003 circular relative to the transfusion act?].

PubMed

Lassale, B; Besse-Moreau, M; Aullen, J-P

2014-11-01

Blood transfusion is currently a delegated medical act in patient care services. Following severe adverse events, hemovigilance now disposes of a dense regulation. Data collection and analysis in the national hemovigilance "e-FIT" database allow detection of errors or malfunctions in the transfusion act. Blood transfusion safety depends on the strict respect of processes from the prescription of blood products and required patient immuno-hematology exams to the administration of blood products and follow-up of the patient. In the circular relative to the transfusion act, many steps of the transfusion process, less explicit, can be interpreted differently by health care professionals and thus lead to errors or severe adverse events. Standardization of procedures for the transfusion act and its surveillance would increase their safety and avoid potential risks for the patient. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Learning from malpractice claims about negligent, adverse events in primary care in the United States

PubMed Central

Phillips, R; Bartholomew, L; Dovey, S; Fryer, G; Miyoshi, T; Green, L

2004-01-01

Background: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. Methods: Physician Insurers Association of America malpractice claims data (1985–2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. Results: Of 49 345 primary care claims, 26 126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). Conclusions: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations. PMID:15069219

Developing a model for the adequate description of electronic communication in hospitals.

PubMed

Saboor, Samrend; Ammenwerth, Elske

2011-01-01

Adequate information and communication systems (ICT) can help to improve the communication in hospitals. Changes to the ICT-infrastructure of hospitals must be planed carefully. In order to support a comprehensive planning, we presented a classification of 81 common errors of the electronic communication on the MIE 2008 congress. Our objective now was to develop a data model that defines specific requirements for an adequate description of electronic communication processes We first applied the method of explicating qualitative content analysis on the error categorization in order to determine the essential process details. After this, we applied the method of subsuming qualitative content analysis on the results of the first step. A data model for the adequate description of electronic communication. This model comprises 61 entities and 91 relationships. The data model comprises and organizes all details that are necessary for the detection of the respective errors. It can be for either used to extend the capabilities of existing modeling methods or as a basis for the development of a new approach.

Physicians' medication prescribing in primary care . in Riyadh City, Saudi Arabia. Literature review, part 3: prescribing errors.

PubMed

Qureshi, N A; Neyaz, Y; Khoja, T; Magzoub, M A; Haycox, A; Walley, T

2011-02-01

Medication errors are globally huge in magnitude and associated with high morbidity and mortality together with high costs and legal problems. Medication errors are caused by multiple factors related to health providers, consumers and health system, but most prescribing errors are preventable. This paper is the third of 3 review articles that form the background for a series of 5 interconnected studies of prescribing patterns and medication errors in the public and private primary health care sectors of Saudi Arabia. A MEDLINE search was conducted to identify papers published in peer-reviewed journals over the previous 3 decades. The paper reviews the etiology, prevention strategies, reporting mechanisms and the myriad consequences of medication errors.

Clover: Compiler directed lightweight soft error resilience

DOE PAGES

Liu, Qingrui; Lee, Dongyoon; Jung, Changhee; ...

2015-05-01

This paper presents Clover, a compiler directed soft error detection and recovery scheme for lightweight soft error resilience. The compiler carefully generates soft error tolerant code based on idem-potent processing without explicit checkpoint. During program execution, Clover relies on a small number of acoustic wave detectors deployed in the processor to identify soft errors by sensing the wave made by a particle strike. To cope with DUE (detected unrecoverable errors) caused by the sensing latency of error detection, Clover leverages a novel selective instruction duplication technique called tail-DMR (dual modular redundancy). Once a soft error is detected by either themore » sensor or the tail-DMR, Clover takes care of the error as in the case of exception handling. To recover from the error, Clover simply redirects program control to the beginning of the code region where the error is detected. Lastly, the experiment results demonstrate that the average runtime overhead is only 26%, which is a 75% reduction compared to that of the state-of-the-art soft error resilience technique.« less

The alarming reality of medication error: a patient case and review of Pennsylvania and National data.

PubMed

da Silva, Brianna A; Krishnamurthy, Mahesh

2016-01-01

A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs) account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Medication reconciliation including an 'indication review' for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider-patient relationship.

An organizational approach to understanding patient safety and medical errors.

PubMed

Kaissi, Amer

2006-01-01

Progress in patient safety, or lack thereof, is a cause for great concern. In this article, we argue that the patient safety movement has failed to reach its goals of eradicating or, at least, significantly reducing errors because of an inappropriate focus on provider and patient-level factors with no real attention to the organizational factors that affect patient safety. We describe an organizational approach to patient safety using different organizational theory perspectives and make several propositions to push patient safety research and practice in a direction that is more likely to improve care processes and outcomes. From a Contingency Theory perspective, we suggest that health care organizations, in general, operate under a misfit between contingencies and structures. This misfit is mainly due to lack of flexibility, cost containment, and lack of regulations, thus explaining the high level of errors committed in these organizations. From an organizational culture perspective, we argue that health care organizations must change their assumptions, beliefs, values, and artifacts to change their culture from a culture of blame to a culture of safety and thus reduce medical errors. From an organizational learning perspective, we discuss how reporting, analyzing, and acting on error information can result in reduced errors in health care organizations.

[Analysis of an incident notification system and register in a critical care unit].

PubMed

Murillo-Pérez, M A; García-Iglesias, M; Palomino-Sánchez, I; Cano Ruiz, G; Cuenca Solanas, M; Alted López, E

2016-01-01

To analyse the incident communicated through a notification system and register in a critical care unit. A cross-sectional descriptive study was conducted by performing an analysis of the records of incidents communicated anonymously and voluntarily from January 2007 to December 2013 in a critical care unit of adult patients with severe trauma. incident type and class, professional reports, and suggestions for improvement measures. A descriptive analysis was performed on the variables. Out of a total of 275 incidents reported, 58.5% of them were adverse events. Incident distributed by classes: medication, 33.7%; vascular access-drainage-catheter-sensor, 19.6%; devices-equipment, 13.3%, procedures, 11.5%; airway tract and mechanical ventilation, 10%; nursing care, 4.1%; inter-professional communication, 3%; diagnostic test, 3%; patient identification, 1.1%, and transfusion 0.7%. In the medication group, administrative errors accounted for a total of 62%; in vascular access-drainage-catheter-sensor group, central venous lines, a total of 27%; in devices and equipment group, respirators, a total of 46.9%; in airway self-extubations, a total of 32.1%. As regards to medication errors, 62% were incidents without damage. Incident notification by profession: doctors, 43%, residents, 5.6%, nurses, 51%, and technical assistants, 0.4%. Adverse events are the most communicated incidents. The events related to medication administration are the most frequent, although most of them were without damage. Nurses and doctors communicate the incidents with the same frequency. In order to highlight the low incident notification despite it being an anonymous and volunteer system, therefore, it is suggested to study measurements to increase the level of communication. Copyright © 2016 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

Family matters: dyadic agreement in end-of-life medical decision making.

PubMed

Schmid, Bettina; Allen, Rebecca S; Haley, Philip P; Decoster, Jamie

2010-04-01

We examined race/ethnicity and cultural context within hypothetical end-of-life medical decision scenarios and its influence on patient-proxy agreement. Family dyads consisting of an older adult and 1 family member, typically an adult child, responded to questions regarding the older adult's preferences for cardiopulmonary resuscitation, artificial feeding and fluids, and palliative care in hypothetical illness scenarios. The responses of 34 Caucasian dyads and 30 African American dyads were compared to determine the extent to which family members could accurately predict the treatment preferences of their older relative. We found higher treatment preference agreement among African American dyads compared with Caucasian dyads when considering overall raw difference scores (i.e., overtreatment errors can compensate for undertreatment errors). Prior advance care planning moderated the effect such that lower levels of advance care planning predicted undertreatment errors among African American proxies and overtreatment errors among Caucasian proxies. In contrast, no racial/ethnic differences in treatment preference agreement were found within absolute difference scores (i.e., total error, regardless of the direction of error). This project is one of the first to examine the mediators and moderators of dyadic racial/cultural differences in treatment preference agreement for end-of-life care in hypothetical illness scenarios. Future studies should use mixed method approaches to explore underlying factors for racial differences in patient-proxy agreement as a basis for developing culturally sensitive interventions to reduce racial disparities in end-of-life care options.

Interdisciplinary development and implementation of communication checklist for postoperative management of pediatric airway patients.

PubMed

Kim, Sang W; Maturo, Stephen; Dwyer, Danielle; Monash, Bradley; Yager, Phoebe H; Zanger, Kerstin; Hartnick, Christopher J

2012-01-01

The authors describe their multidisciplinary experience in applying the Institute of Health Improvement methodology to develop a protocol and checklist to reduce communication error during transfer of care for postoperative pediatric surgical airway patients. Preliminary outcome data following implementation of the protocol and checklist are also presented. Prospective study from July 1, 2009, to February 1, 2011. Tertiary care center. Subjects. One hundred twenty-six pediatric airway patients who required coordinated care between Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital. Two sentinel events involving airway emergencies demonstrated a critical need for a standardized, comprehensive instrument that would ensure safe transfer of care. After development and implementation of the protocol and checklist, an initial pilot period on the first set of 9 pediatric airway patients was reassessed. Subsequent prospective 11-month follow-up data of 93 pediatric airway patients were collected and analyzed. A multidisciplinary pediatric team developed and implemented a formalized, postoperative checklist and transfer protocol. After implementation of the checklist and transfer protocol, prospective analysis showed no adverse events from miscommunication during transfer of care over the subsequent 11-month period involving 93 pediatric airway patients. There has been very little written in the quality and safety patient literature about coordinating effective transfer of care between the pediatric surgical and medical subspecialty realms. After design and implementation of a simple, electronically based transfer-of-care checklist and protocol, the number of postsurgical pediatric airway information transfer and communication errors decreased significantly.

Little shop of errors: an innovative simulation patient safety workshop for community health care professionals.

PubMed

Tupper, Judith B; Pearson, Karen B; Meinersmann, Krista M; Dvorak, Jean

2013-06-01

Continuing education for health care workers is an important mechanism for maintaining patient safety and high-quality health care. Interdisciplinary continuing education that incorporates simulation can be an effective teaching strategy for improving patient safety. Health care professionals who attended a recent Patient Safety Academy had the opportunity to experience firsthand a simulated situation that included many potential patient safety errors. This high-fidelity activity combined the best practice components of a simulation and a collaborative experience that promoted interdisciplinary communication and learning. Participants were challenged to see, learn, and experience "ah-ha" moments of insight as a basis for error reduction and quality improvement. This innovative interdisciplinary educational training method can be offered in place of traditional lecture or online instruction in any facility, hospital, nursing home, or community care setting. Copyright 2013, SLACK Incorporated.

Team safety and innovation by learning from errors in long-term care settings.

PubMed

Buljac-Samardžić, Martina; van Woerkom, Marianne; Paauwe, Jaap

2012-01-01

Team safety and team innovation are underexplored in the context of long-term care. Understanding the issues requires attention to how teams cope with error. Team managers could have an important role in developing a team's error orientation and managing team membership instabilities. The aim of this study was to examine the impact of team member stability, team coaching, and a team's error orientation on team safety and innovation. A cross-sectional survey method was employed within 2 long-term care organizations. Team members and team managers received a survey that measured safety and innovation. Team members assessed member stability, team coaching, and team error orientation (i.e., problem-solving and blaming approach). The final sample included 933 respondents from 152 teams. Stable teams and teams with managers who take on the role of coach are more likely to adopt a problem-solving approach and less likely to adopt a blaming approach toward errors. Both error orientations are related to team member ratings of safety and innovation, but only the blaming approach is (negatively) related to manager ratings of innovation. Differences between members' and managers' ratings of safety are greater in teams with relatively high scores for the blaming approach and relatively low scores for the problem-solving approach. Team coaching was found to be positively related to innovation, especially in unstable teams. Long-term care organizations that wish to enhance team safety and innovation should encourage a problem-solving approach and discourage a blaming approach. Team managers can play a crucial role in this by coaching team members to see errors as sources of learning and improvement and ensuring that individuals will not be blamed for errors.

Refractive errors among patients attending the ophthalmology department of a medical college in North-East India

PubMed Central

Natung, Tanie; Taye, Trishna; Lyngdoh, Laura Amanda; Dkhar, Begonia; Hajong, Ranendra

2017-01-01

Purpose: To determine the magnitude and pattern of refractive errors among patients attending the ophthalmology department of a new medical college in North-East India. Materials and Methods: A prospective study of the new patients (age ≥5 years), who were phakic and whose unaided visual acuities were worse than 20/20 but improved with pinhole, was done. Complete ophthalmic examination and refraction with appropriate cycloplegia for age were done for the 4582 eligible patients. Spherical equivalents (SE) of refractive errors of the right eyes were used for analysis. Results: Of the 4582 eligible patients, 2546 patients had refractive errors (55.56%). The proportion of emmetropia (SE − 0.50–+0.50 diopter sphere [DS]), myopia (SE <−0.50 DS), high myopia (SE >−5.0 DS), and hypermetropia (>+0.50 DS for adults and >+2.0 DS for children) were 53.1%, 27.4%, 2.6%, and 16.9%, respectively. The proportion of hyperopia increased till 59 years and then decreased with age (P = 0.000). The proportion of myopia and high myopia decreased significantly with age after 39 years (P = 0.000 and P = 0.004, respectively). Of the 1510 patients with astigmatism, 17% had with-the-rule (WTR), 23.4% had against-the-rule (ATR), and 19% had oblique astigmatisms. The proportion of WTR and ATR astigmatisms significantly decreased (P = 0.000) and increased (P = 0.000) with age, respectively. Conclusions: This study has provided the magnitude and pattern of refractive errors in the study population. It will serve as the initial step for conducting community-based studies on the prevalence of refractive errors in this part of the country since such data are lacking from this region. Moreover, this study will help the primary care physicians to have an overview of the magnitude and pattern of refractive errors presenting to a health-care center as refractive error is an established and significant public health problem worldwide. PMID:29417005

Refractive errors among patients attending the ophthalmology department of a medical college in North-East India.

PubMed

Natung, Tanie; Taye, Trishna; Lyngdoh, Laura Amanda; Dkhar, Begonia; Hajong, Ranendra

2017-01-01

To determine the magnitude and pattern of refractive errors among patients attending the ophthalmology department of a new medical college in North-East India. A prospective study of the new patients (age ≥5 years), who were phakic and whose unaided visual acuities were worse than 20/20 but improved with pinhole, was done. Complete ophthalmic examination and refraction with appropriate cycloplegia for age were done for the 4582 eligible patients. Spherical equivalents (SE) of refractive errors of the right eyes were used for analysis. Of the 4582 eligible patients, 2546 patients had refractive errors (55.56%). The proportion of emmetropia (SE - 0.50-+0.50 diopter sphere [DS]), myopia (SE <-0.50 DS), high myopia (SE >-5.0 DS), and hypermetropia (>+0.50 DS for adults and >+2.0 DS for children) were 53.1%, 27.4%, 2.6%, and 16.9%, respectively. The proportion of hyperopia increased till 59 years and then decreased with age ( P = 0.000). The proportion of myopia and high myopia decreased significantly with age after 39 years ( P = 0.000 and P = 0.004, respectively). Of the 1510 patients with astigmatism, 17% had with-the-rule (WTR), 23.4% had against-the-rule (ATR), and 19% had oblique astigmatisms. The proportion of WTR and ATR astigmatisms significantly decreased ( P = 0.000) and increased ( P = 0.000) with age, respectively. This study has provided the magnitude and pattern of refractive errors in the study population. It will serve as the initial step for conducting community-based studies on the prevalence of refractive errors in this part of the country since such data are lacking from this region. Moreover, this study will help the primary care physicians to have an overview of the magnitude and pattern of refractive errors presenting to a health-care center as refractive error is an established and significant public health problem worldwide.

Extrasystoles: side effect of kangaroo care?

PubMed

Kluthe, Christof; Wauer, Roland R; Rüdiger, Mario

2004-09-01

To present an unpublished reason for an arrhythmic electrocardiogram (ECG) recording during kangaroo care in a preterm infant. Case report. Preterm infant. A preterm infant exhibited cardiac arrhythmia on the ECG monitor during kangaroo care, leading to interruption of kangarooing. Arrhythmia disappeared after placing the baby back into the incubator. The most likely reasons for arrhythmia were excluded. However, arrhythmia reappeared upon continuation of kangaroo care. ECG monitoring revealed the reason for the monitoring error. ECG monitoring during kangaroo care should cause error because of superimposed electric activity from the parent. Oxygen saturation represents a more reliable method of monitoring during kangaroo care.

The science of medical decision making: neurosurgery, errors, and personal cognitive strategies for improving quality of care.

PubMed

Fargen, Kyle M; Friedman, William A

2014-01-01

During the last 2 decades, there has been a shift in the U.S. health care system towards improving the quality of health care provided by enhancing patient safety and reducing medical errors. Unfortunately, surgical complications, patient harm events, and malpractice claims remain common in the field of neurosurgery. Many of these events are potentially avoidable. There are an increasing number of publications in the medical literature in which authors address cognitive errors in diagnosis and treatment and strategies for reducing such errors, but these are for the most part absent in the neurosurgical literature. The purpose of this article is to highlight the complexities of medical decision making to a neurosurgical audience, with the hope of providing insight into the biases that lead us towards error and strategies to overcome our innate cognitive deficiencies. To accomplish this goal, we review the current literature on medical errors and just culture, explain the dual process theory of cognition, identify common cognitive errors affecting neurosurgeons in practice, review cognitive debiasing strategies, and finally provide simple methods that can be easily assimilated into neurosurgical practice to improve clinical decision making. Copyright © 2014 Elsevier Inc. All rights reserved.

Online Error Reporting for Managing Quality Control Within Radiology.

PubMed

Golnari, Pedram; Forsberg, Daniel; Rosipko, Beverly; Sunshine, Jeffrey L

2016-06-01

Information technology systems within health care, such as picture archiving and communication system (PACS) in radiology, can have a positive impact on production but can also risk compromising quality. The widespread use of PACS has removed the previous feedback loop between radiologists and technologists. Instead of direct communication of quality discrepancies found for an examination, the radiologist submitted a paper-based quality-control report. A web-based issue-reporting tool can help restore some of the feedback loop and also provide possibilities for more detailed analysis of submitted errors. The purpose of this study was to evaluate the hypothesis that data from use of an online error reporting software for quality control can focus our efforts within our department. For the 372,258 radiologic examinations conducted during the 6-month period study, 930 errors (390 exam protocol, 390 exam validation, and 150 exam technique) were submitted, corresponding to an error rate of 0.25 %. Within the category exam protocol, technologist documentation had the highest number of submitted errors in ultrasonography (77 errors [44 %]), while imaging protocol errors were the highest subtype error for computed tomography modality (35 errors [18 %]). Positioning and incorrect accession had the highest errors in the exam technique and exam validation error category, respectively, for nearly all of the modalities. An error rate less than 1 % could signify a system with a very high quality; however, a more likely explanation is that not all errors were detected or reported. Furthermore, staff reception of the error reporting system could also affect the reporting rate.

Paediatric electronic infusion calculator: An intervention to eliminate infusion errors in paediatric critical care.

PubMed

Venkataraman, Aishwarya; Siu, Emily; Sadasivam, Kalaimaran

2016-11-01

Medication errors, including infusion prescription errors are a major public health concern, especially in paediatric patients. There is some evidence that electronic or web-based calculators could minimise these errors. To evaluate the impact of an electronic infusion calculator on the frequency of infusion errors in the Paediatric Critical Care Unit of The Royal London Hospital, London, United Kingdom. We devised an electronic infusion calculator that calculates the appropriate concentration, rate and dose for the selected medication based on the recorded weight and age of the child and then prints into a valid prescription chart. Electronic infusion calculator was implemented from April 2015 in Paediatric Critical Care Unit. A prospective study, five months before and five months after implementation of electronic infusion calculator, was conducted. Data on the following variables were collected onto a proforma: medication dose, infusion rate, volume, concentration, diluent, legibility, and missing or incorrect patient details. A total of 132 handwritten prescriptions were reviewed prior to electronic infusion calculator implementation and 119 electronic infusion calculator prescriptions were reviewed after electronic infusion calculator implementation. Handwritten prescriptions had higher error rate (32.6%) as compared to electronic infusion calculator prescriptions (<1%) with a p  < 0.001. Electronic infusion calculator prescriptions had no errors on dose, volume and rate calculation as compared to handwritten prescriptions, hence warranting very few pharmacy interventions. Use of electronic infusion calculator for infusion prescription significantly reduced the total number of infusion prescribing errors in Paediatric Critical Care Unit and has enabled more efficient use of medical and pharmacy time resources.

Error, stress, and teamwork in medicine and aviation: cross sectional surveys

NASA Technical Reports Server (NTRS)

Sexton, J. B.; Thomas, E. J.; Helmreich, R. L.

2000-01-01

OBJECTIVES: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. DESIGN:: Cross sectional surveys. SETTING:: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. PARTICIPANTS:: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). MAIN OUTCOME MEASURES:: Perceptions of error, stress, and teamwork. RESULTS:: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. CONCLUSIONS: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.

Error, stress, and teamwork in medicine and aviation: cross sectional surveys

PubMed Central

Sexton, J Bryan; Thomas, Eric J; Helmreich, Robert L

2000-01-01

Objectives: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. Design: Cross sectional surveys. Setting: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. Participants: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). Main outcome measures: Perceptions of error, stress, and teamwork. Results: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. Conclusions: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members. PMID:10720356

Common errors of drug administration in infants: causes and avoidance.

PubMed

Anderson, B J; Ellis, J F

1999-01-01

Drug administration errors are common in infants. Although the infant population has a high exposure to drugs, there are few data concerning pharmacokinetics or pharmacodynamics, or the influence of paediatric diseases on these processes. Children remain therapeutic orphans. Formulations are often suitable only for adults; in addition, the lack of maturation of drug elimination processes, alteration of body composition and influence of size render the calculation of drug doses complex in infants. The commonest drug administration error in infants is one of dose, and the commonest hospital site for this error is the intensive care unit. Drug errors are a consequence of system error, and preventive strategies are possible through system analysis. The goal of a zero drug error rate should be aggressively sought, with systems in place that aim to eliminate the effects of inevitable human error. This involves review of the entire system from drug manufacture to drug administration. The nuclear industry, telecommunications and air traffic control services all practise error reduction policies with zero error as a clear goal, not by finding fault in the individual, but by identifying faults in the system and building into that system mechanisms for picking up faults before they occur. Such policies could be adapted to medicine using interventions both specific (the production of formulations which are for children only and clearly labelled, regular audit by pharmacists, legible prescriptions, standardised dose tables) and general (paediatric drug trials, education programmes, nonpunitive error reporting) to reduce the number of errors made in giving medication to infants.

Clinical implications and economic impact of accuracy differences among commercially available blood glucose monitoring systems.

PubMed

Budiman, Erwin S; Samant, Navendu; Resch, Ansgar

2013-03-01

Despite accuracy standards, there are performance differences among commercially available blood glucose monitoring (BGM) systems. The objective of this analysis was to assess the potential clinical and economic impact of accuracy differences of various BGM systems using a modeling approach. We simulated additional risk of hypoglycemia due to blood glucose (BG) measurement errors of five different BGM systems based on results of a real-world accuracy study, while retaining other sources of glycemic variability. Using data from published literature, we estimated an annual additional number of required medical interventions as a result of hypoglycemia. We based our calculations on patients with type 1 diabetes mellitus (T1DM) and T2DM requiring multiple daily injections (MDIs) of insulin in a U.S. health care system. We estimated additional costs attributable to treatment of severe hypoglycemic episodes resulting from BG measurement errors. Results from our model predict an annual difference of approximately 296,000 severe hypoglycemic episodes from BG measurement errors for T1DM (105,000 for T2DM MDI) patients for the estimated U.S. population of 958,800 T1DM and 1,353,600 T2DM MDI patients, using the least accurate BGM system versus patients using the most accurate system in a U.S. health care system. This resulted in additional direct costs of approximately $339 million for T1DM and approximately $121 million for T2DM MDI patients per year. Our analysis shows that error patterns over the operating range of BGM meter may lead to relevant clinical and economic outcome differences that may not be reflected in a common accuracy metric or standard. Further research is necessary to validate the findings of this model-based approach. © 2013 Diabetes Technology Society.

Clinical Implications and Economic Impact of Accuracy Differences among Commercially Available Blood Glucose Monitoring Systems

PubMed Central

Budiman, Erwin S.; Samant, Navendu; Resch, Ansgar

2013-01-01

Background Despite accuracy standards, there are performance differences among commercially available blood glucose monitoring (BGM) systems. The objective of this analysis was to assess the potential clinical and economic impact of accuracy differences of various BGM systems using a modeling approach. Methods We simulated additional risk of hypoglycemia due to blood glucose (BG) measurement errors of five different BGM systems based on results of a real-world accuracy study, while retaining other sources of glycemic variability. Using data from published literature, we estimated an annual additional number of required medical interventions as a result of hypoglycemia. We based our calculations on patients with type 1 diabetes mellitus (T1DM) and T2DM requiring multiple daily injections (MDIs) of insulin in a U.S. health care system. We estimated additional costs attributable to treatment of severe hypoglycemic episodes resulting from BG measurement errors.. Results Results from our model predict an annual difference of approximately 296,000 severe hypoglycemic episodes from BG measurement errors for T1DM (105,000 for T2DM MDI) patients for the estimated U.S. population of 958,800 T1DM and 1,353,600 T2DM MDI patients, using the least accurate BGM system versus patients using the most accurate system in a U.S. health care system. This resulted in additional direct costs of approximately $339 million for T1DM and approximately $121 million for T2DM MDI patients per year. Conclusions Our analysis shows that error patterns over the operating range of BGM meter may lead to relevant clinical and economic outcome differences that may not be reflected in a common accuracy metric or standard. PMID:23566995

Physician's error: medical or legal concept?

PubMed

Mujovic-Zornic, Hajrija M

2010-06-01

This article deals with the common term of different physician's errors that often happen in daily practice of health care. Author begins with the term of medical malpractice, defined broadly as practice of unjustified acts or failures to act upon the part of a physician or other health care professionals, which results in harm to the patient. It is a common term that includes many types of medical errors, especially physician's errors. The author also discusses the concept of physician's error in particular, which is understood no more in traditional way only as classic error in acting something manually wrong without necessary skills (medical concept), but as an error which violates patient's basic rights and which has its final legal consequence (legal concept). In every case the essential element of liability is to establish this error as a breach of the physician's duty. The first point to note is that the standard of procedure and the standard of due care against which the physician will be judged is not going to be that of the ordinary reasonable man who enjoys no medical expertise. The court's decision should give finale answer and legal qualification in each concrete case. The author's conclusion is that higher protection of human rights in the area of health equaly demands broader concept of physician's error with the accent to its legal subject matter.

Peripheral Quantitative Computed Tomography: Measurement Sensitivity in Persons With and Without Spinal Cord Injury

PubMed Central

Shields, Richard K.; Dudley-Javoroski, Shauna; Boaldin, Kathryn M.; Corey, Trent A.; Fog, Daniel B.; Ruen, Jacquelyn M.

2012-01-01

Objectives To determine (1) the error attributable to external tibia-length measurements by using peripheral quantitative computed tomography (pQCT) and (2) the effect these errors have on scan location and tibia trabecular bone mineral density (BMD) after spinal cord injury (SCI). Design Blinded comparison and criterion standard in matched cohorts. Setting Primary care university hospital. Participants Eight able-bodied subjects underwent tibia length measurement. A separate cohort of 7 men with SCI and 7 able-bodied age-matched male controls underwent pQCT analysis. Interventions Not applicable. Main Outcome Measures The projected worst-case tibia-length–measurement error translated into a pQCT slice placement error of ±3mm. We collected pQCT slices at the distal 4% tibia site, 3mm proximal and 3mm distal to that site, and then quantified BMD error attributable to slice placement. Results Absolute BMD error was greater for able-bodied than for SCI subjects (5.87mg/cm3 vs 4.5mg/cm3). However, the percentage error in BMD was larger for SCI than able-bodied subjects (4.56% vs 2.23%). Conclusions During cross-sectional studies of various populations, BMD differences up to 5% may be attributable to variation in limb-length–measurement error. PMID:17023249

Prescribing errors in adult congenital heart disease patients admitted to a pediatric cardiovascular intensive care unit.

PubMed

Echeta, Genevieve; Moffett, Brady S; Checchia, Paul; Benton, Mary Kay; Klouda, Leda; Rodriguez, Fred H; Franklin, Wayne

2014-01-01

Adults with congenital heart disease (CHD) are often cared for at pediatric hospitals. There are no data describing the incidence or type of medication prescribing errors in adult patients admitted to a pediatric cardiovascular intensive care unit (CVICU). A review of patients >18 years of age admitted to the pediatric CVICU at our institution from 2009 to 2011 occurred. A comparator group <18 years of age but >70 kg (a typical adult weight) was identified. Medication prescribing errors were determined according to a commonly used adult drug reference. An independent panel consisting of a physician specializing in the care of adult CHD patients, a nurse, and a pharmacist evaluated all errors. Medication prescribing orders were classified as appropriate, underdose, overdose, or nonstandard (dosing per weight instead of standard adult dosing), and severity of error was classified. Eighty-five adult (74 patients) and 33 pediatric admissions (32 patients) met study criteria (mean age 27.5 ± 9.4 years, 53% male vs. 14.9 ± 1.8 years, 63% male). A cardiothoracic surgical procedure occurred in 81.4% of admissions. Adult admissions weighed less than pediatric admissions (72.8 ± 22.4 kg vs. 85.6 ± 14.9 kg, P < .01) but hospital length of stay was similar. (Adult 6 days [range 1-216 days]; pediatric 5 days [Range 2-123 days], P = .52.) A total of 112 prescribing errors were identified and they occurred less often in adults (42.4% of admissions vs. 66.7% of admissions, P = .02). Adults had a lower mean number of errors (0.7 errors per adult admission vs. 1.7 errors per pediatric admission, P < .01). Prescribing errors occurred most commonly with antimicrobials (n = 27). Underdosing was the most common category of prescribing error. Most prescribing errors were determined to have not caused harm to the patient. Prescribing errors occur frequently in adult patients admitted to a pediatric CVICU but occur more often in pediatric patients of adult weight. © 2013 Wiley Periodicals, Inc.

Identifying types and causes of errors in mortality data in a clinical registry using multiple information systems.

PubMed

Koetsier, Antonie; Peek, Niels; de Keizer, Nicolette

2012-01-01

Errors may occur in the registration of in-hospital mortality, making it less reliable as a quality indicator. We assessed the types of errors made in in-hospital mortality registration in the clinical quality registry National Intensive Care Evaluation (NICE) by comparing its mortality data to data from a national insurance claims database. Subsequently, we performed site visits at eleven Intensive Care Units (ICUs) to investigate the number, types and causes of errors made in in-hospital mortality registration. A total of 255 errors were found in the NICE registry. Two different types of software malfunction accounted for almost 80% of the errors. The remaining 20% were five types of manual transcription errors and human failures to record outcome data. Clinical registries should be aware of the possible existence of errors in recorded outcome data and understand their causes. In order to prevent errors, we recommend to thoroughly verify the software that is used in the registration process.

Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis.

PubMed

Elsaid, K; Truong, T; Monckeberg, M; McCarthy, H; Butera, J; Collins, C

2013-12-01

To evaluate the impact of electronic standardized chemotherapy templates on incidence and types of prescribing errors. A quasi-experimental interrupted time series with segmented regression. A 700-bed multidisciplinary tertiary care hospital with an ambulatory cancer center. A multidisciplinary team including oncology physicians, nurses, pharmacists and information technologists. Standardized, regimen-specific, chemotherapy prescribing forms were developed and implemented over a 32-month period. Trend of monthly prevented prescribing errors per 1000 chemotherapy doses during the pre-implementation phase (30 months), immediate change in the error rate from pre-implementation to implementation and trend of errors during the implementation phase. Errors were analyzed according to their types: errors in communication or transcription, errors in dosing calculation and errors in regimen frequency or treatment duration. Relative risk (RR) of errors in the post-implementation phase (28 months) compared with the pre-implementation phase was computed with 95% confidence interval (CI). Baseline monthly error rate was stable with 16.7 prevented errors per 1000 chemotherapy doses. A 30% reduction in prescribing errors was observed with initiating the intervention. With implementation, a negative change in the slope of prescribing errors was observed (coefficient = -0.338; 95% CI: -0.612 to -0.064). The estimated RR of transcription errors was 0.74; 95% CI (0.59-0.92). The estimated RR of dosing calculation errors was 0.06; 95% CI (0.03-0.10). The estimated RR of chemotherapy frequency/duration errors was 0.51; 95% CI (0.42-0.62). Implementing standardized chemotherapy-prescribing templates significantly reduced all types of prescribing errors and improved chemotherapy safety.

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.

PubMed

Pickering, Brian W; Hurley, Killian; Marsh, Brian

2009-11-01

To use a handover assessment tool for identifying patient information corruption and objectively evaluating interventions designed to reduce handover errors and improve medical decision making. The continuous monitoring, intervention, and evaluation of the patient in modern intensive care unit practice generates large quantities of information, the platform on which medical decisions are made. Information corruption, defined as errors of distortion/omission compared with the medical record, may result in medical judgment errors. Identifying these errors may lead to quality improvements in intensive care unit care delivery and safety. Handover assessment instrument development study divided into two phases by the introduction of a handover intervention. Closed, 17-bed, university-affiliated mixed surgical/medical intensive care unit. Senior and junior medical members of the intensive care unit team. Electronic handover page. Study subjects were asked to recall clinical information commonly discussed at handover on individual patients. The handover score measured the percentage of information correctly retained for each individual doctor-patient interaction. The clinical intention score, a subjective measure of medical judgment, was graded (1-5) by three blinded intensive care unit experts. A total of 137 interactions were scored. Median (interquartile range) handover scores for phases 1 and 2 were 79.07% (67.44-84.50) and 83.72% (76.16-88.37), respectively. Score variance was reduced by the handover intervention (p < .05). Increasing median handover scores, 68.60 to 83.72, were associated with increases in clinical intention scores from 1 to 5 (chi-square = 23.59, df = 4, p < .0001). When asked to recall clinical information discussed at handover, medical members of the intensive care unit team provide data that are significantly corrupted compared with the medical record. Low subjective clinical judgment scores are significant associated with low handover scores. The handover/clinical intention scores may, therefore, be useful screening tools for intensive care unit system vulnerability to medical error. Additionally, handover instruments can identify interventions that reduce system vulnerability to error and may be used to guide quality improvements in handover practice.

A randomized trial comparing INR monitoring devices in patients with anticoagulation self-management: evaluation of a novel error-grid approach.

PubMed

Hemkens, Lars G; Hilden, Kristian M; Hartschen, Stephan; Kaiser, Thomas; Didjurgeit, Ulrike; Hansen, Roland; Bender, Ralf; Sawicki, Peter T

2008-08-01

In addition to the metrological quality of international normalized ratio (INR) monitoring devices used in patients' self-management of long-term anticoagulation, the effectiveness of self-monitoring with such devices has to be evaluated under real-life conditions with a focus on clinical implications. An approach to evaluate the clinical significance of inaccuracies is the error-grid analysis as already established in self-monitoring of blood glucose. Two anticoagulation monitors were compared in a real-life setting and a novel error-grid instrument for oral anticoagulation has been evaluated. In a randomized crossover study 16 patients performed self-management of anticoagulation using the INRatio and the CoaguChek S system. Main outcome measures were clinically relevant INR differences according to established criteria and to the error-grid approach. A lower rate of clinically relevant disagreements according to Anderson's criteria was found with CoaguChek S than with INRatio without statistical significance (10.77% vs. 12.90%; P = 0.787). Using the error-grid we found principally consistent results: More measurement pairs with discrepancies of no or low clinical relevance were found with CoaguChek S, whereas with INRatio we found more differences with a moderate clinical relevance. A high rate of patients' satisfaction with both of the point of care devices was found with only marginal differences. A principal appropriateness of the investigated point-of-care devices to adequately monitor the INR is shown. The error-grid is useful for comparing monitoring methods with a focus on clinical relevance under real-life conditions beyond assessing the pure metrological quality, but we emphasize that additional trials using this instrument with larger patient populations are needed to detect differences in clinically relevant disagreements.

A Real-World Setting Study: Which Glucose Meter Could Be the Best for POCT Use? An Easy and Applicable Protocol During the Hospital Routine.

PubMed

Mancini, Alessio; Esposto, Giampaolo; Manfrini, Silvana; Rilli, Silvia; Tinti, Gessica; Carta, Giuseppe; Petrolati, Laura; Vidali, Matteo; Barocci, Simone

2018-05-01

The aim of this retrospective study is to evaluate the reliability and robustness of six glucose meters for point-of-care testing in our wards using a brand-new protocol. During a 30-days study period a total of 50 diabetes patients were subjected to venous blood sampling and glucose meter blood analysis. The results of six glucose meters were compared with our laboratory reference assay. GlucoMen Plus (Menarini) with the 82% of acceptable results was the most robust glucose meter. Even if the Passing-Bablok analysis demonstrates the presence of constant systematic errors and the Bland-Altman test highlighted a possible overestimation, the surveillance error grid analysis showed that this glucose meter can be used safely. We proved that portable glucose meters are not always reliable in routinely clinical settings.

Eliciting the Functional Processes of Apologizing for Errors in Health Care: Developing an Explanatory Model of Apology.

PubMed

Prothero, Marie M; Morse, Janice M

2017-01-01

The purpose of this article was to analyze the concept development of apology in the context of errors in health care, the administrative response, policy and format/process of the subsequent apology. Using pragmatic utility and a systematic review of the literature, 29 articles and one book provided attributes involved in apologizing. Analytic questions were developed to guide the data synthesis and types of apologies used in different circumstances identified. The antecedents of apologizing, and the attributes and outcomes were identified. A model was constructed illustrating the components of a complete apology, other types of apologies, and ramifications/outcomes of each. Clinical implications of developing formal policies for correcting medical errors through apologies are recommended. Defining the essential elements of apology is the first step in establishing a just culture in health care. Respect for patient-centered care reduces the retaliate consequences following an error, and may even restore the physician patient relationship.

Errors, near misses and adverse events in the emergency department: what can patients tell us?

PubMed

Friedman, Steven M; Provan, David; Moore, Shannon; Hanneman, Kate

2008-09-01

We sought to determine whether patients or their families could identify adverse events in the emergency department (ED), to characterize patient reports of errors and to compare patient reports to events recorded by health care providers. This was a prospective cohort study in a quaternary care inner city teaching hospital with approximately 40,000 annual visits. ED patients were recruited for participation in a standardized interview within 24 hours of ED discharge and a follow-up interview 3-7 days after discharge. Responses regarding events were tabulated and compared with physician and nurse notations in the medical record and hospital event reporting system. Of 292 eligible patients, 201 (69%) were interviewed within 24 hours of ED discharge, and 143 (71% of interviewees) underwent a follow-up interview 3-7 days after discharge. Interviewees did not differ from the base ED population in terms of age, sex or language. Analysis of patient interviews identified 10 adverse events (5% incident rate; 95% confidence interval [CI] 2.41%-8.96%), 8 near misses (4% incident rate; 95% CI 1.73%-7.69%) and no medical errors. Of the 10 adverse events, 6 (60%) were characterized as preventable (2 raters; kappa=0.78, standard error [SE] 0.20; 95% CI 0.39-1.00; p=0.01). Adverse events were primarily related to delayed or inadequate analgesia. Only 4 out of 8 (50%) near misses were intercepted by hospital personnel. The secondary interview elicited 2 out of 10 adverse events and 3 out of 8 near misses that had not been identified in the primary interview. No designation (0 out of 10) of an adverse event was recorded in the ED medical record or in the confidential hospital event reporting system. ED patients can identify adverse events affecting their care. Moreover, many of these events are not recorded in the medical record. Engaging patients and their family members in identification of errors may enhance patient safety.

Problems and pitfalls in cardiac drug therapy.

PubMed

Stone, S M; Rai, N; Nei, J

2001-01-01

Medical errors in the care of patients may account for 44,000 to 98,000 deaths per year, and 7,000 deaths per year are attributed to medication errors alone. Increasing awareness among health care providers of potential errors is a critical step toward improving the safety of medical care. Because today's medications are increasingly complex, approved at an accelerated rate, and often have a narrow therapeutic window with only a small margin of safety, patient and provider education is critical in assuring optimal therapeutic outcomes. Providers can use electronic resources such as Web sites to keep informed on drug-drug, drug-food, and drug-nutritional supplements interactions.

Prevalence of medication errors in primary health care at Bahrain Defence Force Hospital – prescription-based study

PubMed Central

Aljasmi, Fatema; Almalood, Fatema

2018-01-01

Background One of the important activities that physicians – particularly general practitioners – perform is prescribing. It occurs in most health care facilities and especially in primary health care (PHC) settings. Objectives This study aims to determine what types of prescribing errors are made in PHC at Bahrain Defence Force (BDF) Hospital, and how common they are. Methods This was a retrospective study of data from PHC at BDF Hospital. The data consisted of 379 prescriptions randomly selected from the pharmacy between March and May 2013, and errors in the prescriptions were classified into five types: major omission, minor omission, commission, integration, and skill-related errors. Results Of the total prescriptions, 54.4% (N=206) were given to male patients and 45.6% (N=173) to female patients; 24.8% were given to patients under the age of 10 years. On average, there were 2.6 drugs per prescription. In the prescriptions, 8.7% of drugs were prescribed by their generic names, and 28% (N=106) of prescriptions included an antibiotic. Out of the 379 prescriptions, 228 had an error, and 44.3% (N=439) of the 992 prescribed drugs contained errors. The proportions of errors were as follows: 9.9% (N=38) were minor omission errors; 73.6% (N=323) were major omission errors; 9.3% (N=41) were commission errors; and 17.1% (N=75) were skill-related errors. Conclusion This study provides awareness of the presence of prescription errors and frequency of the different types of errors that exist in this hospital. Understanding the different types of errors could help future studies explore the causes of specific errors and develop interventions to reduce them. Further research should be conducted to understand the causes of these errors and demonstrate whether the introduction of electronic prescriptions has an effect on patient outcomes. PMID:29445304

Addressing Medical Errors in Hand Surgery

PubMed Central

Johnson, Shepard P.; Adkinson, Joshua M.; Chung, Kevin C.

2014-01-01

Influential think-tank such as the Institute of Medicine has raised awareness about the implications of medical errors. In response, organizations, medical societies, and institutions have initiated programs to decrease the incidence and effects of these errors. Surgeons deal with the direct implications of adverse events involving patients. In addition to managing the physical consequences, they are confronted with ethical and social issues when caring for a harmed patient. Although there is considerable effort to implement system-wide changes, there is little guidance for hand surgeons on how to address medical errors. Admitting an error is difficult, but a transparent environment where patients are notified of errors and offered consolation and compensation is essential to maintain trust. Further, equipping hand surgeons with a guide for addressing medical errors will promote compassionate patient interaction, help identify system failures, provide learning points for safety improvement, and demonstrate a commitment to ethically responsible medical care. PMID:25154576

Learning from Mistakes

PubMed Central

Fischer, Melissa A; Mazor, Kathleen M; Baril, Joann; Alper, Eric; DeMarco, Deborah; Pugnaire, Michele

2006-01-01

CONTEXT Trainees are exposed to medical errors throughout medical school and residency. Little is known about what facilitates and limits learning from these experiences. OBJECTIVE To identify major factors and areas of tension in trainees' learning from medical errors. DESIGN, SETTING, AND PARTICIPANTS Structured telephone interviews with 59 trainees (medical students and residents) from 1 academic medical center. Five authors reviewed transcripts of audiotaped interviews using content analysis. RESULTS Trainees were aware that medical errors occur from early in medical school. Many had an intense emotional response to the idea of committing errors in patient care. Students and residents noted variation and conflict in institutional recommendations and individual actions. Many expressed role confusion regarding whether and how to initiate discussion after errors occurred. Some noted the conflict between reporting errors to seniors who were responsible for their evaluation. Learners requested more open discussion of actual errors and faculty disclosure. No students or residents felt that they learned better from near misses than from actual errors, and many believed that they learned the most when harm was caused. CONCLUSIONS Trainees are aware of medical errors, but remaining tensions may limit learning. Institutions can immediately address variability in faculty response and local culture by disseminating clear, accessible algorithms to guide behavior when errors occur. Educators should develop longitudinal curricula that integrate actual cases and faculty disclosure. Future multi-institutional work should focus on identified themes such as teaching and learning in emotionally charged situations, learning from errors and near misses and balance between individual and systems responsibility. PMID:16704381

Organizational safety culture and medical error reporting by Israeli nurses.

PubMed

Kagan, Ilya; Barnoy, Sivia

2013-09-01

To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%). The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data. Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance. This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level. A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety. © 2013 Sigma Theta Tau International.

Classifying nursing errors in clinical management within an Australian hospital.

PubMed

Tran, D T; Johnson, M

2010-12-01

Although many classification systems relating to patient safety exist, no taxonomy was identified that classified nursing errors in clinical management. To develop a classification system for nursing errors relating to clinical management (NECM taxonomy) and to describe contributing factors and patient consequences. We analysed 241 (11%) self-reported incidents relating to clinical management in nursing in a metropolitan hospital. Descriptive analysis of numeric data and content analysis of text data were undertaken to derive the NECM taxonomy, contributing factors and consequences for patients. Clinical management incidents represented 1.63 incidents per 1000 occupied bed days. The four themes of the NECM taxonomy were nursing care process (67%), communication (22%), administrative process (5%), and knowledge and skill (6%). Half of the incidents did not cause any patient harm. Contributing factors (n=111) included the following: patient clinical, social conditions and behaviours (27%); resources (22%); environment and workload (18%); other health professionals (15%); communication (13%); and nurse's knowledge and experience (5%). The NECM taxonomy provides direction to clinicians and managers on areas in clinical management that are most vulnerable to error, and therefore, priorities for system change management. Any nurses who wish to classify nursing errors relating to clinical management could use these types of errors. This study informs further research into risk management behaviour, and self-assessment tools for clinicians. Globally, nurses need to continue to monitor and act upon patient safety issues. © 2010 The Authors. International Nursing Review © 2010 International Council of Nurses.

Disinfection of reusable elastomeric respirators by health care workers: a feasibility study and development of standard operating procedures.

PubMed

Bessesen, Mary T; Adams, Jill C; Radonovich, Lewis; Anderson, Judith

2015-06-01

This was a feasibility study in a Department of Veterans Affairs Medical Center to develop a standard operating procedure (SOP) to be used by health care workers to disinfect reusable elastomeric respirators under pandemic conditions. Registered and licensed practical nurses, nurse practitioners, aides, clinical technicians, and physicians took part in the study. Health care worker volunteers were provided with manufacturers' cleaning and disinfection instructions and all necessary supplies. They were observed and filmed. SOPs were developed, based on these observations, and tested on naïve volunteer health care workers. Error rates using manufacturers' instructions and SOPs were compared. When using respirator manufacturers' cleaning and disinfection instructions, without specific training or supervision, all subjects made multiple errors. When using the SOPs developed in the study, without specific training or guidance, naïve health care workers disinfected respirators with zero errors. Reusable facial protective equipment may be disinfected by health care workers with minimal training using SOPs. Published by Elsevier Inc.

Preventability of Voluntarily Reported or Trigger Tool-Identified Medication Errors in a Pediatric Institution by Information Technology: A Retrospective Cohort Study.

PubMed

Stultz, Jeremy S; Nahata, Milap C

2015-07-01

Information technology (IT) has the potential to prevent medication errors. While many studies have analyzed specific IT technologies and preventable adverse drug events, no studies have identified risk factors for errors still occurring that are not preventable by IT. The objective of this study was to categorize reported or trigger tool-identified errors and adverse events (AEs) at a pediatric tertiary care institution. Also, we sought to identify medication errors preventable by IT, determine why IT-preventable errors occurred, and to identify risk factors for errors that were not preventable by IT. This was a retrospective analysis of voluntarily reported or trigger tool-identified errors and AEs occurring from 1 July 2011 to 30 June 2012. Medication errors reaching the patients were categorized based on the origin, severity, and location of the error, the month in which they occurred, and the age of the patient involved. Error characteristics were included in a multivariable logistic regression model to determine independent risk factors for errors occurring that were not preventable by IT. A medication error was defined as a medication-related failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. An IT-preventable error was defined as having an IT system in place to aid in prevention of the error at the phase and location of its origin. There were 936 medication errors (identified by voluntarily reporting or a trigger tool system) included and analyzed. Drug administration errors were identified most frequently (53.4% ), but prescribing errors most frequently caused harm (47.2 % of harmful errors). There were 470 (50.2 %) errors that were IT preventable at their origin, including 155 due to IT system bypasses, 103 due to insensitivity of IT alerting systems, and 47 with IT alert overrides. Dispensing, administration, and documentation errors had higher odds than prescribing errors for being not preventable by IT [odds ratio (OR) 8.0, 95 % CI 4.4-14.6; OR 2.4, 95 % CI 1.7-3.7; and OR 6.7, 95 % CI 3.3-14.5, respectively; all p < 0.001). Errors occurring in the operating room and in the outpatient setting had higher odds than intensive care units for being not preventable by IT (OR 10.4, 95 % CI 4.0-27.2, and OR 2.6, 95 % CI 1.3-5.0, respectively; all p ≤ 0.004). Despite extensive IT implementation at the studied institution, approximately one-half of the medication errors identified by voluntarily reporting or a trigger tool system were not preventable by the utilized IT systems. Inappropriate use of IT systems was a common cause of errors. The identified risk factors represent areas where IT safety features were lacking.

Improving end of life care: an information systems approach to reducing medical errors.

PubMed

Tamang, S; Kopec, D; Shagas, G; Levy, K

2005-01-01

Chronic and terminally ill patients are disproportionately affected by medical errors. In addition, the elderly suffer more preventable adverse events than younger patients. Targeting system wide "error-reducing" reforms to vulnerable populations can significantly reduce the incidence and prevalence of human error in medical practice. Recent developments in health informatics, particularly the application of artificial intelligence (AI) techniques such as data mining, neural networks, and case-based reasoning (CBR), presents tremendous opportunities for mitigating error in disease diagnosis and patient management. Additionally, the ubiquity of the Internet creates the possibility of an almost ideal network for the dissemination of medical information. We explore the capacity and limitations of web-based palliative information systems (IS) to transform the delivery of care, streamline processes and improve the efficiency and appropriateness of medical treatment. As a result, medical error(s) that occur with patients dealing with severe, chronic illness and the frail elderly can be reduced.The palliative model grew out of the need for pain relief and comfort measures for patients diagnosed with cancer. Applied definitions of palliative care extend this convention, but there is no widely accepted definition. This research will discuss the development life cycle of two palliative information systems: the CONFER QOLP management information system (MIS), currently used by a community-based palliative care program in Brooklyn, New York, and the CAREN case-based reasoning prototype. CONFER is a web platform based on the idea of "eCare". CONFER uses XML (extensible mark-up language), a W3C-endorced standard mark up to define systems data. The second system, CAREN, is a CBR prototype designed for palliative care patients in the cancer trajectory. CBR is a technique, which tries to exploit the similarities of two situations and match decision-making to the best-known precedent cases. The prototype uses the opensource CASPIAN shell developed by the University of Aberystwyth, Wales and is available by anonymous FTP. We will discuss and analyze the preliminary results we have obtained using this CBR tool. Our research suggests that automated information systems can be used to improve the quality of care at the end of life and disseminate expert level 'know how' to palliative care clinicians. We will present how our CBR prototype can be successfully deployed, capable of securely transferring information using a Secure File Transfer Protocol (SFTP) and using a JAVA CBR engine.

Analysis of S-box in Image Encryption Using Root Mean Square Error Method

NASA Astrophysics Data System (ADS)

Hussain, Iqtadar; Shah, Tariq; Gondal, Muhammad Asif; Mahmood, Hasan

2012-07-01

The use of substitution boxes (S-boxes) in encryption applications has proven to be an effective nonlinear component in creating confusion and randomness. The S-box is evolving and many variants appear in literature, which include advanced encryption standard (AES) S-box, affine power affine (APA) S-box, Skipjack S-box, Gray S-box, Lui J S-box, residue prime number S-box, Xyi S-box, and S8 S-box. These S-boxes have algebraic and statistical properties which distinguish them from each other in terms of encryption strength. In some circumstances, the parameters from algebraic and statistical analysis yield results which do not provide clear evidence in distinguishing an S-box for an application to a particular set of data. In image encryption applications, the use of S-boxes needs special care because the visual analysis and perception of a viewer can sometimes identify artifacts embedded in the image. In addition to existing algebraic and statistical analysis already used for image encryption applications, we propose an application of root mean square error technique, which further elaborates the results and enables the analyst to vividly distinguish between the performances of various S-boxes. While the use of the root mean square error analysis in statistics has proven to be effective in determining the difference in original data and the processed data, its use in image encryption has shown promising results in estimating the strength of the encryption method. In this paper, we show the application of the root mean square error analysis to S-box image encryption. The parameters from this analysis are used in determining the strength of S-boxes

A novel approach for evaluating the risk of health care failure modes.

PubMed

Chang, Dong Shang; Chung, Jenq Hann; Sun, Kuo Lung; Yang, Fu Chiang

2012-12-01

Failure mode and effects analysis (FMEA) can be employed to reduce medical errors by identifying the risk ranking of the health care failure modes and taking priority action for safety improvement. The purpose of this paper is to propose a novel approach of data analysis. The approach is to integrate FMEA and a mathematical tool-Data envelopment analysis (DEA) with "slack-based measure" (SBM), in the field of data analysis. The risk indexes (severity, occurrence, and detection) of FMEA are viewed as multiple inputs of DEA. The practicality and usefulness of the proposed approach is illustrated by one case of health care. Being a systematic approach for improving the service quality of health care, the approach can offer quantitative corrective information of risk indexes that thereafter reduce failure possibility. For safety improvement, these new targets of the risk indexes could be used for management by objectives. But FMEA cannot provide quantitative corrective information of risk indexes. The novel approach can surely overcome this chief shortcoming of FMEA. After combining DEA SBM model with FMEA, the two goals-increase of patient safety, medical cost reduction-can be together achieved.

Primary care physicians' use of an electronic medical record system: a cognitive task analysis.

PubMed

Shachak, Aviv; Hadas-Dayagi, Michal; Ziv, Amitai; Reis, Shmuel

2009-03-01

To describe physicians' patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient-doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. Cognitive task analysis using semi-structured interviews and field observations. Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. The comprehensiveness, organization, and readability of data in the EMR system reduced physicians' need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient's chart. EMR use interfered with patient-doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians' communication skills also helped. There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians' offices and by enhancing physicians' computer and communication skills.

Primary Care Physicians’ Use of an Electronic Medical Record System: A Cognitive Task Analysis

PubMed Central

Hadas-Dayagi, Michal; Ziv, Amitai; Reis, Shmuel

2009-01-01

OBJECTIVE To describe physicians’ patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient–doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. DESIGN Cognitive task analysis using semi-structured interviews and field observations. PARTICIPANTS Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. RESULTS The comprehensiveness, organization, and readability of data in the EMR system reduced physicians’ need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient’s chart. EMR use interfered with patient–doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians’ communication skills also helped. CONCLUSIONS There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians’ offices and by enhancing physicians’ computer and communication skills. PMID:19130148

Evaluation of a point-of-care glucose and β-hydroxybutyrate meter operated in various environmental conditions in prepartum and postpartum sheep.

PubMed

Hornig, Katlin J; Byers, Stacey R; Callan, Robert J; Holt, Timothy; Field, Megan; Han, Hyungchul

2013-08-01

To compare β-hydroxybutyrate (BHB) and glucose concentrations measured with a dual-purpose point-of-care (POC) meter designed for use in humans and a laboratory biochemical analyzer (LBA) to determine whether the POC meter would be reliable for on-farm measurement of blood glucose and BHB concentrations in sheep in various environmental conditions and nutritional states. 36 pregnant mixed-breed ewes involved in a maternal feed restriction study. Blood samples were collected from each sheep at multiple points throughout gestation and lactation to allow for tracking of gradually increasing metabolic hardship. Whole blood glucose and BHB concentrations were measured with the POC meter and compared with serum results obtained with an LBA. 464 samples were collected. Whole blood BHB concentrations measured with the POC meter compared well with LBA results, and error grid analysis showed the POC values were acceptable. Whole blood glucose concentrations measured with the POC meter had more variation, compared with LBA values, over the glucose ranges evaluated. Results of error grid analysis of POC-measured glucose concentrations were not acceptable, indicating errors likely to result in needless treatment with glucose or other supplemental energy sources in normoglycemic sheep. The POC meter was user-friendly and performed well across a wide range of conditions. The meter was adequate for detection of pregnancy toxemia in sheep via whole blood BHB concentration. Results should be interpreted with caution when the POC meter is used to measure blood glucose concentrations.

ISMP Medication Error Report Analysis: Understanding Human Over-reliance on Technology It's Exelan, Not Exelon Crash Cart Drug Mix-up Risk with Entering a "Test Order".

PubMed

Cohen, Michael R; Smetzer, Judy L

2017-01-01

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Evaluating mixed samples as a source of error in non-invasive genetic studies using microsatellites

USGS Publications Warehouse

Roon, David A.; Thomas, M.E.; Kendall, K.C.; Waits, L.P.

2005-01-01

The use of noninvasive genetic sampling (NGS) for surveying wild populations is increasing rapidly. Currently, only a limited number of studies have evaluated potential biases associated with NGS. This paper evaluates the potential errors associated with analysing mixed samples drawn from multiple animals. Most NGS studies assume that mixed samples will be identified and removed during the genotyping process. We evaluated this assumption by creating 128 mixed samples of extracted DNA from brown bear (Ursus arctos) hair samples. These mixed samples were genotyped and screened for errors at six microsatellite loci according to protocols consistent with those used in other NGS studies. Five mixed samples produced acceptable genotypes after the first screening. However, all mixed samples produced multiple alleles at one or more loci, amplified as only one of the source samples, or yielded inconsistent electropherograms by the final stage of the error-checking process. These processes could potentially reduce the number of individuals observed in NGS studies, but errors should be conservative within demographic estimates. Researchers should be aware of the potential for mixed samples and carefully design gel analysis criteria and error checking protocols to detect mixed samples.

Impact of resident duty hour limits on safety in the intensive care unit: a national survey of pediatric and neonatal intensivists.

PubMed

Typpo, Katri V; Tcharmtchi, M Hossein; Thomas, Eric J; Kelly, P Adam; Castillo, Leticia D; Singh, Hardeep

2012-09-01

Resident duty-hour regulations potentially shift the workload from resident to attending physicians. We sought to understand how current or future regulatory changes might impact safety in academic pediatric and neonatal intensive care units. Web-based survey. U.S. academic pediatric and neonatal intensive care units. Attending pediatric and neonatal intensivists. We evaluated perceptions on four intensive care unit safety-related risk measures potentially affected by current duty-hour regulations: 1) attending physician and resident fatigue; 2) attending physician workload; 3) errors (self-reported rates by attending physicians or perceived resident error rates); and 4) safety culture. We also evaluated perceptions of how these risks would change with further duty-hour restrictions. We administered our survey between February and April 2010 to 688 eligible physicians, of whom 360 (52.3%) responded. Most believed that resident error rates were unchanged or worse (91.9%) and safety culture was unchanged or worse (84.4%) with current duty-hour regulations. Of respondents, 61.9% believed their own work-hours providing direct patient care increased and 55.8% believed they were more fatigued while providing direct patient care. Most (85.3%) perceived no increase in their own error rates currently, but in the scenario of further reduction in resident duty-hours, over half (53.3%) believed that safety culture would worsen and a significant proportion (40.3%) believed that their own error rates would increase. Pediatric intensivists do not perceive improved patient safety from current resident duty-hour restrictions. Policies to further restrict resident duty-hours should consider unintended consequences of worsening certain aspects of intensive care unit safety.

Clinical Risk Assessment in Intensive Care Unit

PubMed Central

Asefzadeh, Saeed; Yarmohammadian, Mohammad H.; Nikpey, Ahmad; Atighechian, Golrokh

2013-01-01

Background: Clinical risk management focuses on improving the quality and safety of health care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks. The goal of this study is to identify and assess the failure modes in the ICU of Qazvin's Social Security Hospital (Razi Hospital) through Failure Mode and Effect Analysis (FMEA). Methods: This was a qualitative-quantitative research by Focus Discussion Group (FDG) performed in Qazvin Province, Iran during 2011. The study population included all individuals and owners who are familiar with the process in ICU. Sampling method was purposeful and the FDG group members were selected by the researcher. The research instrument was standard worksheet that has been used by several researchers. Data was analyzed by FMEA technique. Results: Forty eight clinical errors and failure modes identified, results showed that the highest risk probability number (RPN) was in respiratory care “Ventilator's alarm malfunction (no alarm)” with the score 288, and the lowest was in gastrointestinal “not washing the NG-Tube” with the score 8. Conclusions: Many of the identified errors can be prevented by group members. Clinical risk assessment and management is the key to delivery of effective health care. PMID:23930171

Atmospheric Multiple Scattering Effects on GLAS Altimetry. Part 2; Analysis of Expected Errors in Antarctic Altitude Measurements

NASA Technical Reports Server (NTRS)

Mahesh, Ashwin; Spinhirne, James D.; Duda, David P.; Eloranta, Edwin W.; Starr, David O'C (Technical Monitor)

2001-01-01

The altimetry bias in GLAS (Geoscience Laser Altimeter System) or other laser altimeters resulting from atmospheric multiple scattering is studied in relationship to current knowledge of cloud properties over the Antarctic Plateau. Estimates of seasonal and interannual changes in the bias are presented. Results show the bias in altitude from multiple scattering in clouds would be a significant error source without correction. The selective use of low optical depth clouds or cloudfree observations, as well as improved analysis of the return pulse such as by the Gaussian method used here, are necessary to minimize the surface altitude errors. The magnitude of the bias is affected by variations in cloud height, cloud effective particle size and optical depth. Interannual variations in these properties as well as in cloud cover fraction could lead to significant year-to-year variations in the altitude bias. Although cloud-free observations reduce biases in surface elevation measurements from space, over Antarctica these may often include near-surface blowing snow, also a source of scattering-induced delay. With careful selection and analysis of data, laser altimetry specifications can be met.

Physician assistants and the disclosure of medical error.

PubMed

Brock, Douglas M; Quella, Alicia; Lipira, Lauren; Lu, Dave W; Gallagher, Thomas H

2014-06-01

Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.

Are we under-utilizing the talents of primary care personnel? A job analytic examination

PubMed Central

Hysong, Sylvia J; Best, Richard G; Moore, Frank I

2007-01-01

Background Primary care staffing decisions are often made unsystematically, potentially leading to increased costs, dissatisfaction, turnover, and reduced quality of care. This article aims to (1) catalogue the domain of primary care tasks, (2) explore the complexity associated with these tasks, and (3) examine how tasks performed by different job titles differ in function and complexity, using Functional Job Analysis to develop a new tool for making evidence-based staffing decisions. Methods Seventy-seven primary care personnel from six US Department of Veterans Affairs (VA) Medical Centers, representing six job titles, participated in two-day focus groups to generate 243 unique task statements describing the content of VA primary care. Certified job analysts rated tasks on ten dimensions representing task complexity, skills, autonomy, and error consequence. Two hundred and twenty-four primary care personnel from the same clinics then completed a survey indicating whether they performed each task. Tasks were catalogued using an adaptation of an existing classification scheme; complexity differences were tested via analysis of variance. Results Objective one: Task statements were categorized into four functions: service delivery (65%), administrative duties (15%), logistic support (9%), and workforce management (11%). Objective two: Consistent with expectations, 80% of tasks received ratings at or below the mid-scale value on all ten scales. Objective three: Service delivery and workforce management tasks received higher ratings on eight of ten scales (multiple functional complexity dimensions, autonomy, human error consequence) than administrative and logistic support tasks. Similarly, tasks performed by more highly trained job titles received higher ratings on six of ten scales than tasks performed by lower trained job titles. Contrary to expectations, the distribution of tasks across functions did not significantly vary by job title. Conclusion Primary care personnel are not being utilized to the extent of their training; most personnel perform many tasks that could reasonably be performed by personnel with less training. Primary care clinics should use evidence-based information to optimize job-person fit, adjusting clinic staff mix and allocation of work across staff to enhance efficiency and effectiveness. PMID:17397534

Tubing misconnections--a systems failure with human factors: lessons for nursing practice.

PubMed

Simmons, Debora; Graves, Krisanne

2008-12-01

In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in health care's view of vigilance.

On the importance of Task 1 and error performance measures in PRP dual-task studies.

PubMed

Strobach, Tilo; Schütz, Anja; Schubert, Torsten

2015-01-01

The psychological refractory period (PRP) paradigm is a dominant research tool in the literature on dual-task performance. In this paradigm a first and second component task (i.e., Task 1 and Task 2) are presented with variable stimulus onset asynchronies (SOAs) and priority to perform Task 1. The main indicator of dual-task impairment in PRP situations is an increasing Task 2-RT with decreasing SOAs. This impairment is typically explained with some task components being processed strictly sequentially in the context of the prominent central bottleneck theory. This assumption could implicitly suggest that processes of Task 1 are unaffected by Task 2 and bottleneck processing, i.e., decreasing SOAs do not increase reaction times (RTs) and error rates of the first task. The aim of the present review is to assess whether PRP dual-task studies included both RT and error data presentations and statistical analyses and whether studies including both data types (i.e., RTs and error rates) show data consistent with this assumption (i.e., decreasing SOAs and unaffected RTs and/or error rates in Task 1). This review demonstrates that, in contrast to RT presentations and analyses, error data is underrepresented in a substantial number of studies. Furthermore, a substantial number of studies with RT and error data showed a statistically significant impairment of Task 1 performance with decreasing SOA. Thus, these studies produced data that is not primarily consistent with the strong assumption that processes of Task 1 are unaffected by Task 2 and bottleneck processing in the context of PRP dual-task situations; this calls for a more careful report and analysis of Task 1 performance in PRP studies and for a more careful consideration of theories proposing additions to the bottleneck assumption, which are sufficiently general to explain Task 1 and Task 2 effects.

On the importance of Task 1 and error performance measures in PRP dual-task studies

PubMed Central

Strobach, Tilo; Schütz, Anja; Schubert, Torsten

2015-01-01

The psychological refractory period (PRP) paradigm is a dominant research tool in the literature on dual-task performance. In this paradigm a first and second component task (i.e., Task 1 and Task 2) are presented with variable stimulus onset asynchronies (SOAs) and priority to perform Task 1. The main indicator of dual-task impairment in PRP situations is an increasing Task 2-RT with decreasing SOAs. This impairment is typically explained with some task components being processed strictly sequentially in the context of the prominent central bottleneck theory. This assumption could implicitly suggest that processes of Task 1 are unaffected by Task 2 and bottleneck processing, i.e., decreasing SOAs do not increase reaction times (RTs) and error rates of the first task. The aim of the present review is to assess whether PRP dual-task studies included both RT and error data presentations and statistical analyses and whether studies including both data types (i.e., RTs and error rates) show data consistent with this assumption (i.e., decreasing SOAs and unaffected RTs and/or error rates in Task 1). This review demonstrates that, in contrast to RT presentations and analyses, error data is underrepresented in a substantial number of studies. Furthermore, a substantial number of studies with RT and error data showed a statistically significant impairment of Task 1 performance with decreasing SOA. Thus, these studies produced data that is not primarily consistent with the strong assumption that processes of Task 1 are unaffected by Task 2 and bottleneck processing in the context of PRP dual-task situations; this calls for a more careful report and analysis of Task 1 performance in PRP studies and for a more careful consideration of theories proposing additions to the bottleneck assumption, which are sufficiently general to explain Task 1 and Task 2 effects. PMID:25904890

Advancing the research agenda for diagnostic error reduction.

PubMed

Zwaan, Laura; Schiff, Gordon D; Singh, Hardeep

2013-10-01

Diagnostic errors remain an underemphasised and understudied area of patient safety research. We briefly summarise the methods that have been used to conduct research on epidemiology, contributing factors and interventions related to diagnostic error and outline directions for future research. Research methods that have studied epidemiology of diagnostic error provide some estimate on diagnostic error rates. However, there appears to be a large variability in the reported rates due to the heterogeneity of definitions and study methods used. Thus, future methods should focus on obtaining more precise estimates in different settings of care. This would lay the foundation for measuring error rates over time to evaluate improvements. Research methods have studied contributing factors for diagnostic error in both naturalistic and experimental settings. Both approaches have revealed important and complementary information. Newer conceptual models from outside healthcare are needed to advance the depth and rigour of analysis of systems and cognitive insights of causes of error. While the literature has suggested many potentially fruitful interventions for reducing diagnostic errors, most have not been systematically evaluated and/or widely implemented in practice. Research is needed to study promising intervention areas such as enhanced patient involvement in diagnosis, improving diagnosis through the use of electronic tools and identification and reduction of specific diagnostic process 'pitfalls' (eg, failure to conduct appropriate diagnostic evaluation of a breast lump after a 'normal' mammogram). The last decade of research on diagnostic error has made promising steps and laid a foundation for more rigorous methods to advance the field.

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

PubMed

Keenan, Gail; Yakel, Elizabeth; Dunn Lopez, Karen; Tschannen, Dana; Ford, Yvonne B

2013-01-01

To examine information flow, a vital component of a patient's care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement. This was a qualitative study of a sample of eight medical-surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staff's communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices. Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patient's electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication. The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patient's plan.

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information

PubMed Central

Yakel, Elizabeth; Dunn Lopez, Karen; Tschannen, Dana; Ford, Yvonne B

2013-01-01

Objective To examine information flow, a vital component of a patient's care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement. Design This was a qualitative study of a sample of eight medical–surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staff's communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices. Results Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patient's electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication. Conclusion The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patient's plan. PMID:22822042

Family caregiver learning--how family caregivers learn to provide care at the end of life: a qualitative secondary analysis of four datasets.

PubMed

Stajduhar, Kelli I; Funk, Laura; Outcalt, Linda

2013-07-01

Family caregivers are assuming growing responsibilities in providing care to dying family members. Supporting them is fundamental to ensure quality end-of-life care and to buffer potentially negative outcomes, although family caregivers frequently acknowledge a deficiency of information, knowledge, and skills necessary to assume the tasks involved in this care. The aim of this inquiry was to explore how family caregivers describe learning to provide care to palliative patients. Secondary analysis of data from four qualitative studies (n = 156) with family caregivers of dying people. Data included qualitative interviews with 156 family caregivers of dying people. Family caregivers learn through the following processes: trial and error, actively seeking needed information and guidance, applying knowledge and skills from previous experience, and reflecting on their current experiences. Caregivers generally preferred and appreciated a supported or guided learning process that involved being shown or told by others, usually learning reactively after a crisis. Findings inform areas for future research to identify effective, individualized programs and interventions to support positive learning experiences for family caregivers of dying people.

Clinical decision-making: heuristics and cognitive biases for the ophthalmologist.

PubMed

Hussain, Ahsen; Oestreicher, James

Diagnostic errors have a significant impact on health care outcomes and patient care. The underlying causes and development of diagnostic error are complex with flaws in health care systems, as well as human error, playing a role. Cognitive biases and a failure of decision-making shortcuts (heuristics) are human factors that can compromise the diagnostic process. We describe these mechanisms, their role with the clinician, and provide clinical scenarios to highlight the various points at which biases may emerge. We discuss strategies to modify the development and influence of these processes and the vulnerability of heuristics to provide insight and improve clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Ebola, team communication, and shame: but shame on whom?

PubMed

Shannon, Sarah E

2015-01-01

Examined as an isolated situation, and through the lens of a rare and feared disease, Mr. Duncan's case seems ripe for second-guessing the physicians and nurses who cared for him. But viewed from the perspective of what we know about errors and team communication, his case is all too common. Nearly 440,000 patient deaths in the U.S. each year may be attributable to medical errors. Breakdowns in communication among health care teams contribute in the majority of these errors. The culture of health care does not seem to foster functional, effective communication between and among professionals. Why? And more importantly, why do we not do something about it?

Economic impact of medication error: a systematic review.

PubMed

Walsh, Elaine K; Hansen, Christina Raae; Sahm, Laura J; Kearney, Patricia M; Doherty, Edel; Bradley, Colin P

2017-05-01

Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd. Copyright © 2017 John Wiley & Sons, Ltd.

[Diagnostic Errors in Medicine].

PubMed

Buser, Claudia; Bankova, Andriyana

2015-12-09

The recognition of diagnostic errors in everyday practice can help improve patient safety. The most common diagnostic errors are the cognitive errors, followed by system-related errors and no fault errors. The cognitive errors often result from mental shortcuts, known as heuristics. The rate of cognitive errors can be reduced by a better understanding of heuristics and the use of checklists. The autopsy as a retrospective quality assessment of clinical diagnosis has a crucial role in learning from diagnostic errors. Diagnostic errors occur more often in primary care in comparison to hospital settings. On the other hand, the inpatient errors are more severe than the outpatient errors.

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 45 Public Welfare 1 2011-10-01 2011-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

Dialysis Facility Safety: Processes and Opportunities.

PubMed

Garrick, Renee; Morey, Rishikesh

2015-01-01

Unintentional human errors are the source of most safety breaches in complex, high-risk environments. The environment of dialysis care is extremely complex. Dialysis patients have unique and changing physiology, and the processes required for their routine care involve numerous open-ended interfaces between providers and an assortment of technologically advanced equipment. Communication errors, both within the dialysis facility and during care transitions, and lapses in compliance with policies and procedures are frequent areas of safety risk. Some events, such as air emboli and needle dislodgments occur infrequently, but are serious risks. Other adverse events include medication errors, patient falls, catheter and access-related infections, access infiltrations and prolonged bleeding. A robust safety system should evaluate how multiple, sequential errors might align to cause harm. Systems of care can be improved by sharing the results of root cause analyses, and "good catches." Failure mode effects and analyses can be used to proactively identify and mitigate areas of highest risk, and methods drawn from cognitive psychology, simulation training, and human factor engineering can be used to advance facility safety. © 2015 Wiley Periodicals, Inc.

MAXimising Involvement in MUltiMorbidity (MAXIMUM) in primary care: protocol for an observation and interview study of patients, GPs and other care providers to identify ways of reducing patient safety failures

PubMed Central

Daker-White, Gavin; Hays, Rebecca; Esmail, Aneez; Minor, Brian; Barlow, Wendy; Brown, Benjamin; Blakeman, Thomas; Bower, Peter

2014-01-01

Introduction Increasing numbers of older people are living with multiple long-term health conditions but global healthcare systems and clinical guidelines have traditionally focused on the management of single conditions. Having two or more long-term conditions, or ‘multimorbidity’, is associated with a range of adverse consequences and poor outcomes and could put patients at increased risk of safety failures. Traditionally, most research into patient safety failures has explored hospital or inpatient settings. Much less is known about patient safety failures in primary care. Our core aims are to understand the mechanisms by which multimorbidity leads to safety failures, to explore the different ways in which patients and services respond (or fail to respond), and to identify opportunities for intervention. Methods and analysis We plan to undertake an applied ethnographic study of patients with multimorbidity. Patients’ interactions and environments, relevant to their healthcare, will be studied through observations, diary methods and semistructured interviews. A framework, based on previous studies, will be used to organise the collection and analysis of field notes, observations and other qualitative data. This framework includes the domains: access breakdowns, communication breakdowns, continuity of care errors, relationship breakdowns and technical errors. Ethics and dissemination Ethical approval was received from the National Health Service Research Ethics Committee for Wales. An individual case study approach is likely to be most fruitful for exploring the mechanisms by which multimorbidity leads to safety failures. A longitudinal and multiperspective approach will allow for the constant comparison of patient, carer and healthcare worker expectations and experiences related to the provision, integration and management of complex care. This data will be used to explore ways of engaging patients and carers more in their own care using shared decision-making, patient empowerment or other relevant models. PMID:25138807

Concomitant prescribing and dispensing errors at a Brazilian hospital: a descriptive study

PubMed Central

Silva, Maria das Dores Graciano; Rosa, Mário Borges; Franklin, Bryony Dean; Reis, Adriano Max Moreira; Anchieta, Lêni Márcia; Mota, Joaquim Antônio César

2011-01-01

OBJECTIVE: To analyze the prevalence and types of prescribing and dispensing errors occurring with high-alert medications and to propose preventive measures to avoid errors with these medications. INTRODUCTION: The prevalence of adverse events in health care has increased, and medication errors are probably the most common cause of these events. Pediatric patients are known to be a high-risk group and are an important target in medication error prevention. METHODS: Observers collected data on prescribing and dispensing errors occurring with high-alert medications for pediatric inpatients in a university hospital. In addition to classifying the types of error that occurred, we identified cases of concomitant prescribing and dispensing errors. RESULTS: One or more prescribing errors, totaling 1,632 errors, were found in 632 (89.6%) of the 705 high-alert medications that were prescribed and dispensed. We also identified at least one dispensing error in each high-alert medication dispensed, totaling 1,707 errors. Among these dispensing errors, 723 (42.4%) content errors occurred concomitantly with the prescribing errors. A subset of dispensing errors may have occurred because of poor prescription quality. The observed concomitancy should be examined carefully because improvements in the prescribing process could potentially prevent these problems. CONCLUSION: The system of drug prescribing and dispensing at the hospital investigated in this study should be improved by incorporating the best practices of medication safety and preventing medication errors. High-alert medications may be used as triggers for improving the safety of the drug-utilization system. PMID:22012039

Error Sources in Asteroid Astrometry

NASA Technical Reports Server (NTRS)

Owen, William M., Jr.

2000-01-01

Asteroid astrometry, like any other scientific measurement process, is subject to both random and systematic errors, not all of which are under the observer's control. To design an astrometric observing program or to improve an existing one requires knowledge of the various sources of error, how different errors affect one's results, and how various errors may be minimized by careful observation or data reduction techniques.

A Medication Safety Model: A Case Study in Thai Hospital

PubMed Central

Rattanarojsakul, Phichai; Thawesaengskulthai, Natcha

2013-01-01

Reaching zero defects is vital in medication service. Medication error can be reduced if the causes are recognized. The purpose of this study is to search for a conceptual framework of the causes of medication error in Thailand and to examine relationship between these factors and its importance. The study was carried out upon an in-depth case study and survey of hospital personals who were involved in the drug use process. The structured survey was based on Emergency Care Research Institute (ECRI) (2008) questionnaires focusing on the important factors that affect the medication safety. Additional questionnaires included content to the context of Thailand's private hospital, validated by five-hospital qualified experts. By correlation Pearson analysis, the result revealed 14 important factors showing a linear relationship with drug administration error except the medication reconciliation. By independent sample t-test, the administration error in the hospital was significantly related to external impact. The multiple regression analysis of the detail of medication administration also indicated the patient identification before administration of medication, detection of the risk of medication adverse effects and assurance of medication administration at the right time, dosage and route were statistically significant at 0.05 level. The major implication of the study is to propose a medication safety model in a Thai private hospital. PMID:23985110

A medication safety model: a case study in Thai hospital.

PubMed

Rattanarojsakul, Phichai; Thawesaengskulthai, Natcha

2013-06-12

Reaching zero defects is vital in medication service. Medication error can be reduced if the causes are recognized. The purpose of this study is to search for a conceptual framework of the causes of medication error in Thailand and to examine relationship between these factors and its importance. The study was carried out upon an in-depth case study and survey of hospital personals who were involved in the drug use process. The structured survey was based on Emergency Care Research Institute (ECRI) (2008) questionnaires focusing on the important factors that affect the medication safety. Additional questionnaires included content to the context of Thailand's private hospital, validated by five-hospital qualified experts. By correlation Pearson analysis, the result revealed 14 important factors showing a linear relationship with drug administration error except the medication reconciliation. By independent sample t-test, the administration error in the hospital was significantly related to external impact. The multiple regression analysis of the detail of medication administration also indicated the patient identification before administration of medication, detection of the risk of medication adverse effects and assurance of medication administration at the right time, dosage and route were statistically significant at 0.05 level. The major implication of the study is to propose a medication safety model in a Thai private hospital.

Plan for Quality to Improve Patient Safety at the Point of Care

PubMed Central

Ehrmeyer, Sharon S.

2011-01-01

The U.S. Institute of Medicine (IOM) much publicized report in “To Err is Human” (2000, National Academy Press) stated that as many as 98 000 hospitalized patients in the U.S. die each year due to preventable medical errors. This revelation about medical error and patient safety focused the public and the medical community's attention on errors in healthcare delivery including laboratory and point-of-care-testing (POCT). Errors introduced anywhere in the POCT process clearly can impact quality and place patient's safety at risk. While POCT performed by or near the patient reduces the potential of some errors, the process presents many challenges to quality with its multiple tests sites, test menus, testing devices and non-laboratory analysts, who often have little understanding of quality testing. Incoherent or no regulations and the rapid availability of test results for immediate clinical intervention can further amplify errors. System planning and management of the entire POCT process are essential to reduce errors and improve quality and patient safety. PMID:21808107

Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event.

PubMed

Meurier, C E

2000-07-01

Human errors are common in clinical practice, but they are under-reported. As a result, very little is known of the types, antecedents and consequences of errors in nursing practice. This limits the potential to learn from errors and to make improvement in the quality and safety of nursing care. The aim of this study was to use an Organizational Accident Model to analyse critical incidents of errors in nursing. Twenty registered nurses were invited to produce a critical incident report of an error (which had led to an adverse event or potentially could have led to an adverse event) they had made in their professional practice and to write down their responses to the error using a structured format. Using Reason's Organizational Accident Model, supplemental information was then collected from five of the participants by means of an individual in-depth interview to explore further issues relating to the incidents they had reported. The detailed analysis of one of the incidents is discussed in this paper, demonstrating the effectiveness of this approach in providing insight into the chain of events which may lead to an adverse event. The case study approach using critical incidents of clinical errors was shown to provide relevant information regarding the interaction of organizational factors, local circumstances and active failures (errors) in producing an adverse or potentially adverse event. It is suggested that more use should be made of this approach to understand how errors are made in practice and to take appropriate preventative measures.

The effect of divided attention on novices and experts in laparoscopic task performance.

PubMed

Ghazanfar, Mudassar Ali; Cook, Malcolm; Tang, Benjie; Tait, Iain; Alijani, Afshin

2015-03-01

Attention is important for the skilful execution of surgery. The surgeon's attention during surgery is divided between surgery and outside distractions. The effect of this divided attention has not been well studied previously. We aimed to compare the effect of dividing attention of novices and experts on a laparoscopic task performance. Following ethical approval, 25 novices and 9 expert surgeons performed a standardised peg transfer task in a laboratory setup under three randomly assigned conditions: silent as control condition and two standardised auditory distracting tasks requiring response (easy and difficult) as study conditions. Human reliability assessment was used for surgical task analysis. Primary outcome measures were correct auditory responses, task time, number of surgical errors and instrument movements. Secondary outcome measures included error rate, error probability and hand specific differences. Non-parametric statistics were used for data analysis. 21109 movements and 9036 total errors were analysed. Novices had increased mean task completion time (seconds) (171 ± 44SD vs. 149 ± 34, p < 0.05), number of total movements (227 ± 27 vs. 213 ± 26, p < 0.05) and number of errors (127 ± 51 vs. 96 ± 28, p < 0.05) during difficult study conditions compared to control. The correct responses to auditory stimuli were less frequent in experts (68 %) compared to novices (80 %). There was a positive correlation between error rate and error probability in novices (r (2) = 0.533, p < 0.05) but not in experts (r (2) = 0.346, p > 0.05). Divided attention conditions in theatre environment require careful consideration during surgical training as the junior surgeons are less able to focus their attention during these conditions.

The Nature, Significance, and Evaluation of the Schwarzschild-Villiger (SV) Effect in Photometric Procedures

PubMed Central

Howling, D. H.; Fitzgerald, P. J.

1959-01-01

The Schwarzschild-Villiger effect has been experimentally demonstrated with the optical system used in this laboratory. Using a photographic mosaic specimen as a model, it has been shown that the conclusions of Naora are substantiated and that the SV effect, in large or small magnitude, is always present in optical systems. The theoretical transmission error arising from the presence of the SV effect has been derived for various optical conditions of measurement. The results have been experimentally confirmed. The SV contribution of the substage optics of microspectrophotometers has also been considered. A simple method of evaluating a flare function f(A) is advanced which provides a measure of the SV error present in a system. It is demonstrated that measurements of specimens of optical density less than unity can be made with less than 1 per cent error, when using illuminating beam diameter/specimen diameter ratios of unity and uncoated optical surfaces. For denser specimens it is shown that care must be taken to reduce the illuminating beam/specimen diameter ratio to a value dictated by the magnitude of a flare function f(A), evaluated for a particular optical system, in order to avoid excessive transmission error. It is emphasized that observed densities (transmissions) are not necessarily true densities (transmissions) because of the possibility of SV error. The ambiguity associated with an estimation of stray-light error by means of an opaque object has also been demonstrated. The errors illustrated are not necessarily restricted to microspectrophotometry but may possibly be found in such fields as spectral analysis, the interpretation of x-ray diffraction patterns, the determination of ionizing particle tracks and particle densities in photographic emulsions, and in many other types of photometric analysis. PMID:14403512

Piloting Medication Histories in a Pediatric Postanesthesia Care Unit.

PubMed

Lake, Nathan; Nawer, Humaira; Wagner, Deborah

2018-05-18

Develop a medication history process for pediatric postanesthesia care unit (PACU) patients to identify discrepancies between home and inpatient medications and prevent medication errors. Pilot an evidence-based practice change to perform PACU medication histories. Inpatients or surgical admissions to general care units at a pediatric tertiary care 348-bed hospital ages 2-18 years were included. Parents/guardians were asked about their child's prescription and over-the-counter medications, allergies, and adherence. Data included patient age, surgery, medication categories, and error classifications. Information was compared to the patient's medical record. From June to July 2016, 75 medication histories were performed, covering 44.6% of eligible cases within the period. Seventy-four discrepancies were found, the most frequent being omission. The medication category with the most errors was vitamins/herbals/supplements. The workflow designed assessed discrepancy frequency and type in surgical patients' medication lists when transitioning from the PACU to general care units. Copyright © 2018 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Effects of a direct refill program for automated dispensing cabinets on medication-refill errors.

PubMed

Helmons, Pieter J; Dalton, Ashley J; Daniels, Charles E

2012-10-01

The effects of a direct refill program for automated dispensing cabinets (ADCs) on medication-refill errors were studied. This study was conducted in designated acute care areas of a 386-bed academic medical center. A wholesaler-to-ADC direct refill program, consisting of prepackaged delivery of medications and bar-code-assisted ADC refilling, was implemented in the inpatient pharmacy of the medical center in September 2009. Medication-refill errors in 26 ADCs from the general medicine units, the infant special care unit, the surgical and burn intensive care units, and intermediate units were assessed before and after the implementation of this program. Medication-refill errors were defined as an ADC pocket containing the wrong drug, wrong strength, or wrong dosage form. ADC refill errors decreased by 77%, from 62 errors per 6829 refilled pockets (0.91%) to 8 errors per 3855 refilled pockets (0.21%) (p < 0.0001). The predominant error type detected before the intervention was the incorrect medication (wrong drug, wrong strength, or wrong dosage form) in the ADC pocket. Of the 54 incorrect medications found before the intervention, 38 (70%) were loaded in a multiple-drug drawer. After the implementation of the new refill process, 3 of the 5 incorrect medications were loaded in a multiple-drug drawer. There were 3 instances of expired medications before and only 1 expired medication after implementation of the program. A redesign of the ADC refill process using a wholesaler-to-ADC direct refill program that included delivery of prepackaged medication and bar-code-assisted refill significantly decreased the occurrence of ADC refill errors.

Prescribing Errors Involving Medication Dosage Forms

PubMed Central

Lesar, Timothy S

2002-01-01

CONTEXT Prescribing errors involving medication dose formulations have been reported to occur frequently in hospitals. No systematic evaluations of the characteristics of errors related to medication dosage formulation have been performed. OBJECTIVE To quantify the characteristics, frequency, and potential adverse patient effects of prescribing errors involving medication dosage forms . DESIGN Evaluation of all detected medication prescribing errors involving or related to medication dosage forms in a 631-bed tertiary care teaching hospital. MAIN OUTCOME MEASURES Type, frequency, and potential for adverse effects of prescribing errors involving or related to medication dosage forms. RESULTS A total of 1,115 clinically significant prescribing errors involving medication dosage forms were detected during the 60-month study period. The annual number of detected errors increased throughout the study period. Detailed analysis of the 402 errors detected during the last 16 months of the study demonstrated the most common errors to be: failure to specify controlled release formulation (total of 280 cases; 69.7%) both when prescribing using the brand name (148 cases; 36.8%) and when prescribing using the generic name (132 cases; 32.8%); and prescribing controlled delivery formulations to be administered per tube (48 cases; 11.9%). The potential for adverse patient outcome was rated as potentially “fatal or severe” in 3 cases (0.7%), and “serious” in 49 cases (12.2%). Errors most commonly involved cardiovascular agents (208 cases; 51.7%). CONCLUSIONS Hospitalized patients are at risk for adverse outcomes due to prescribing errors related to inappropriate use of medication dosage forms. This information should be considered in the development of strategies to prevent adverse patient outcomes resulting from such errors. PMID:12213138

Health care work environments, employee satisfaction, and patient safety: Care provider perspectives.

PubMed

Rathert, Cheryl; May, Douglas R

2007-01-01

Experts continue to decry the lack of progress made in decreasing the alarming frequency of medical errors in health care organizations (Leape, L. L., & Berwick, D. M. (2005). Five years after to err is human: What have we learned?. Journal of the American Medical Association, 293(19), 2384-2390). At the same time, other experts are concerned about the lack of job satisfaction and turnover among nurses (. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press). Research and theory suggest that a work environment that facilitates patient-centered care should increase patient safety and nurse satisfaction. The present study began with a conceptual model that specifies how work environment variables should be related to both nurse and patient outcomes. Specifically, we proposed that health care work units with climates for patient-centered care should have nurses who are more satisfied with their jobs. Such units should also have higher levels of patient safety, with fewer medication errors. We examined perceptions of nurses from three acute care hospitals in the eastern United States. Nurses who perceived their work units as more patient centered were significantly more satisfied with their jobs than were those whose units were perceived as less patient centered. Those whose work units were more patient centered reported that medication errors occurred less frequently in their units and said that they felt more comfortable reporting errors and near-misses than those in less patient-centered units. Patients and quality leaders continue to call for delivery of patient-centered care. If climates that facilitate such care are also related to improved patient safety and nurse satisfaction, proactive, patient-centered management of the work environment could result in improved patient, employee, and organizational outcomes.

Comparison of Agar Dilution, Disk Diffusion, MicroScan, and Vitek Antimicrobial Susceptibility Testing Methods to Broth Microdilution for Detection of Fluoroquinolone-Resistant Isolates of the Family Enterobacteriaceae

PubMed Central

Steward, Christine D.; Stocker, Sheila A.; Swenson, Jana M.; O’Hara, Caroline M.; Edwards, Jonathan R.; Gaynes, Robert P.; McGowan, John E.; Tenover, Fred C.

1999-01-01

Fluoroquinolone resistance appears to be increasing in many species of bacteria, particularly in those causing nosocomial infections. However, the accuracy of some antimicrobial susceptibility testing methods for detecting fluoroquinolone resistance remains uncertain. Therefore, we compared the accuracy of the results of agar dilution, disk diffusion, MicroScan Walk Away Neg Combo 15 conventional panels, and Vitek GNS-F7 cards to the accuracy of the results of the broth microdilution reference method for detection of ciprofloxacin and ofloxacin resistance in 195 clinical isolates of the family Enterobacteriaceae collected from six U.S. hospitals for a national surveillance project (Project ICARE [Intensive Care Antimicrobial Resistance Epidemiology]). For ciprofloxacin, very major error rates were 0% (disk diffusion and MicroScan), 0.9% (agar dilution), and 2.7% (Vitek), while major error rates ranged from 0% (agar dilution) to 3.7% (MicroScan and Vitek). Minor error rates ranged from 12.3% (agar dilution) to 20.5% (MicroScan). For ofloxacin, no very major errors were observed, and major errors were noted only with MicroScan (3.7% major error rate). Minor error rates ranged from 8.2% (agar dilution) to 18.5% (Vitek). Minor errors for all methods were substantially reduced when results with MICs within ±1 dilution of the broth microdilution reference MIC were excluded from analysis. However, the high number of minor errors by all test systems remains a concern. PMID:9986809

Medication errors: problems and recommendations from a consensus meeting

PubMed Central

Agrawal, Abha; Aronson, Jeffrey K; Britten, Nicky; Ferner, Robin E; de Smet, Peter A; Fialová, Daniela; Fitzgerald, Richard J; Likić, Robert; Maxwell, Simon R; Meyboom, Ronald H; Minuz, Pietro; Onder, Graziano; Schachter, Michael; Velo, Giampaolo

2009-01-01

Here we discuss 15 recommendations for reducing the risks of medication errors: Provision of sufficient undergraduate learning opportunities to make medical students safe prescribers. Provision of opportunities for students to practise skills that help to reduce errors. Education of students about common types of medication errors and how to avoid them. Education of prescribers in taking accurate drug histories. Assessment in medical schools of prescribing knowledge and skills and demonstration that newly qualified doctors are safe prescribers. European harmonization of prescribing and safety recommendations and regulatory measures, with regular feedback about rational drug use. Comprehensive assessment of elderly patients for declining function. Exploration of low-dose regimens for elderly patients and preparation of special formulations as required. Training for all health-care professionals in drug use, adverse effects, and medication errors in elderly people. More involvement of pharmacists in clinical practice. Introduction of integrated prescription forms and national implementation in individual countries. Development of better monitoring systems for detecting medication errors, based on classification and analysis of spontaneous reports of previous reactions, and for investigating the possible role of medication errors when patients die. Use of IT systems, when available, to provide methods of avoiding medication errors; standardization, proper evaluation, and certification of clinical information systems. Nonjudgmental communication with patients about their concerns and elicitation of symptoms that they perceive to be adverse drug reactions. Avoidance of defensive reactions if patients mention symptoms resulting from medication errors. PMID:19594525

Error management training and simulation education.

PubMed

Gardner, Aimee; Rich, Michelle

2014-12-01

The integration of simulation into the training of health care professionals provides context for decision making and procedural skills in a high-fidelity environment, without risk to actual patients. It was hypothesised that a novel approach to simulation-based education - error management training - would produce higher performance ratings compared with traditional step-by-step instruction. Radiology technology students were randomly assigned to participate in traditional procedural-based instruction (n = 11) or vicarious error management training (n = 11). All watched an instructional video and discussed how well each incident was handled (traditional instruction group) or identified where the errors were made (vicarious error management training). Students then participated in a 30-minute case-based simulation. Simulations were videotaped for performance analysis. Blinded experts evaluated performance using a predefined evaluation tool created specifically for the scenario. Blinded experts evaluated performance using a predefined evaluation tool created specifically for the scenario The vicarious error management group scored higher on observer-rated performance (Mean = 9.49) than students in the traditional instruction group (Mean = 9.02; p < 0.01). These findings suggest that incorporating the discussion of errors and how to handle errors during the learning session will better equip students when performing hands-on procedures and skills. This pilot study provides preliminary evidence for integrating error management skills into medical curricula and for the design of learning goals in simulation-based education. © 2014 John Wiley & Sons Ltd.

The economics of health care quality and medical errors.

PubMed

Andel, Charles; Davidow, Stephen L; Hollander, Mark; Moreno, David A

2012-01-01

Hospitals have been looking for ways to improve quality and operational efficiency and cut costs for nearly three decades, using a variety of quality improvement strategies. However, based on recent reports, approximately 200,000 Americans die from preventable medical errors including facility-acquired conditions and millions may experience errors. In 2008, medical errors cost the United States $19.5 billion. About 87 percent or $17 billion were directly associated with additional medical cost, including: ancillary services, prescription drug services, and inpatient and outpatient care, according to a study sponsored by the Society for Actuaries and conducted by Milliman in 2010. Additional costs of $1.4 billion were attributed to increased mortality rates with $1.1 billion or 10 million days of lost productivity from missed work based on short-term disability claims. The authors estimate that the economic impact is much higher, perhaps nearly $1 trillion annually when quality-adjusted life years (QALYs) are applied to those that die. Using the Institute of Medicine's (IOM) estimate of 98,000 deaths due to preventable medical errors annually in its 1998 report, To Err Is Human, and an average of ten lost years of life at $75,000 to $100,000 per year, there is a loss of $73.5 billion to $98 billion in QALYs for those deaths--conservatively. These numbers are much greater than those we cite from studies that explore the direct costs of medical errors. And if the estimate of a recent Health Affairs article is correct-preventable death being ten times the IOM estimate-the cost is $735 billion to $980 billion. Quality care is less expensive care. It is better, more efficient, and by definition, less wasteful. It is the right care, at the right time, every time. It should mean that far fewer patients are harmed or injured. Obviously, quality care is not being delivered consistently throughout U.S. hospitals. Whatever the measure, poor quality is costing payers and society a great deal. However, health care leaders and professionals are focusing on quality and patient safety in ways they never have before because the economics of quality have changed substantially.

Point-of-care blood glucose measurement errors overestimate hypoglycaemia rates in critically ill patients.

PubMed

Nya-Ngatchou, Jean-Jacques; Corl, Dawn; Onstad, Susan; Yin, Tom; Tylee, Tracy; Suhr, Louise; Thompson, Rachel E; Wisse, Brent E

2015-02-01

Hypoglycaemia is associated with morbidity and mortality in critically ill patients, and many hospitals have programmes to minimize hypoglycaemia rates. Recent studies have established the hypoglycaemic patient-day as a key metric and have published benchmark inpatient hypoglycaemia rates on the basis of point-of-care blood glucose data even though these values are prone to measurement errors. A retrospective, cohort study including all patients admitted to Harborview Medical Center Intensive Care Units (ICUs) during 2010 and 2011 was conducted to evaluate a quality improvement programme to reduce inappropriate documentation of point-of-care blood glucose measurement errors. Laboratory Medicine point-of-care blood glucose data and patient charts were reviewed to evaluate all episodes of hypoglycaemia. A quality improvement intervention decreased measurement errors from 31% of hypoglycaemic (<70 mg/dL) patient-days in 2010 to 14% in 2011 (p < 0.001) and decreased the observed hypoglycaemia rate from 4.3% of ICU patient-days to 3.4% (p < 0.001). Hypoglycaemic events were frequently recurrent or prolonged (~40%), and these events are not identified by the hypoglycaemic patient-day metric, which also may be confounded by a large number of very low risk or minimally monitored patient-days. Documentation of point-of-care blood glucose measurement errors likely overestimates ICU hypoglycaemia rates and can be reduced by a quality improvement effort. The currently used hypoglycaemic patient-day metric does not evaluate recurrent or prolonged events that may be more likely to cause patient harm. The monitored patient-day as currently defined may not be the optimal denominator to determine inpatient hypoglycaemic risk. Copyright © 2014 John Wiley & Sons, Ltd.

AGILE: Autonomous Global Integrated Language Exploitation

DTIC Science & Technology

2009-12-01

combination, including METEOR-based alignment (with stemming and WordNet synonym matching) and GIZA ++ based alignment. So far, we have not seen any...parse trees and a detailed analysis of how function words operate in translation. This program lets us fix alignment errors that systems like GIZA ...correlates better with Pyramid than with Responsiveness scoring (i.e., it is a more precise, careful, measure) • BE generally outperforms ROUGE

A Radial Basis Function Approach to Financial Time Series Analysis

DTIC Science & Technology

1993-12-01

including efficient methods for parameter estimation and pruning, a pointwise prediction error estimator, and a methodology for controlling the "data...collection of practical techniques to address these issues for a modeling methodology . Radial Basis Function networks. These techniques in- clude efficient... methodology often then amounts to a careful consideration of the interplay between model complexity and reliability. These will be recurrent themes

Students' Perceptions of Patient Safety during the Transition from Undergraduate to Postgraduate Training: An Activity Theory Analysis

ERIC Educational Resources Information Center

de Feijter, Jeantine M.; de Grave, Willem S.; Dornan, Tim; Koopmans, Richard P.; Scherpbier, Albert J. J. A.

2011-01-01

Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is…

[Patient safety and errors in medicine: development, prevention and analyses of incidents].

PubMed

Rall, M; Manser, T; Guggenberger, H; Gaba, D M; Unertl, K

2001-06-01

"Patient safety" and "errors in medicine" are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a "systems" approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology--within which realistic simulators were developed--is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of "culture" throughout the entire health care system. The "culture of blame" focused on individuals should be replaced by a "safety culture", that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a "preventive and proactive safety culture" should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient safety must have the highest priority in the goals of the institution: "Primum nihil nocere"--"First, do not harm".

Assessing explicit error reporting in the narrative electronic medical record using keyword searching.

PubMed

Cao, Hui; Stetson, Peter; Hripcsak, George

2003-01-01

Many types of medical errors occur in and outside of hospitals, some of which have very serious consequences and increase cost. Identifying errors is a critical step for managing and preventing them. In this study, we assessed the explicit reporting of medical errors in the electronic record. We used five search terms "mistake," "error," "incorrect," "inadvertent," and "iatrogenic" to survey several sets of narrative reports including discharge summaries, sign-out notes, and outpatient notes from 1991 to 2000. We manually reviewed all the positive cases and identified them based on the reporting of physicians. We identified 222 explicitly reported medical errors. The positive predictive value varied with different keywords. In general, the positive predictive value for each keyword was low, ranging from 3.4 to 24.4%. Therapeutic-related errors were the most common reported errors and these reported therapeutic-related errors were mainly medication errors. Keyword searches combined with manual review indicated some medical errors that were reported in medical records. It had a low sensitivity and a moderate positive predictive value, which varied by search term. Physicians were most likely to record errors in the Hospital Course and History of Present Illness sections of discharge summaries. The reported errors in medical records covered a broad range and were related to several types of care providers as well as non-health care professionals.

The PoET (Prevention of Error-Based Transfers) Project.

PubMed

Oliver, Jill; Chidwick, Paula

2017-01-01

The PoET (Prevention of Error-based Transfers) Project is one of the Ethics Quality Improvement Projects (EQIPs) taking place at William Osler Health System. This specific project is designed to reduce transfers from long-term care to hospital that are caused by legal and ethical errors related to consent, capacity and substitute decision-making. The project is currently operating in eight long-term care homes in the Central West Local Health Integration Network and has seen a 56% reduction in multiple transfers before death in hospital.

Developing an eLearning tool formalizing in YAWL the guidelines used in a transfusion medicine service.

PubMed

Russo, Paola; Piazza, Miriam; Leonardi, Giorgio; Roncoroni, Layla; Russo, Carlo; Spadaro, Salvatore; Quaglini, Silvana

2012-01-01

The blood transfusion is a complex activity subject to a high risk of eventually fatal errors. The development and application of computer-based systems could help reducing the error rate, playing a fundamental role in the improvement of the quality of care. This poster presents an under development eLearning tool formalizing the guidelines of the transfusion process. This system, implemented in YAWL (Yet Another Workflow Language), will be used to train the personnel in order to improve the efficiency of care and to reduce errors.

Effect of therapeutic interchange on medication reconciliation during hospitalization and upon discharge in a geriatric population

PubMed Central

Wang, Jessica S.; Fogerty, Robert L.

2017-01-01

Background Therapeutic interchange of a same class medication for an outpatient medication is a widespread practice during hospitalization in response to limited hospital formularies. However, therapeutic interchange may increase risk of medication errors. The objective was to characterize the prevalence and safety of therapeutic interchange. Methods and findings Secondary analysis of a transitions of care study. We included patients over age 64 admitted to a tertiary care hospital between 2009–2010 with heart failure, pneumonia, or acute coronary syndrome who were taking a medication in any of six commonly-interchanged classes on admission: proton pump inhibitors (PPIs), histamine H2-receptor antagonists (H2 blockers), hydroxymethylglutaryl CoA reductase inhibitors (statins), angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and inhaled corticosteroids (ICS). There was limited electronic medication reconciliation support available. Main measures were presence and accuracy of therapeutic interchange during hospitalization, and rate of medication reconciliation errors on discharge. We examined charts of 303 patients taking 555 medications at time of admission in the six medication classes of interest. A total of 244 (44.0%) of medications were therapeutically interchanged to an approved formulary drug at admission, affecting 64% of the study patients. Among the therapeutically interchanged drugs, we identified 78 (32.0%) suspected medication conversion errors. The discharge medication reconciliation error rate was 11.5% among the 244 therapeutically interchanged medications, compared with 4.2% among the 311 unchanged medications (relative risk [RR] 2.75, 95% confidence interval [CI] 1.45–5.19). Conclusions Therapeutic interchange was prevalent among hospitalized patients in this study and elevates the risk for potential medication errors during and after hospitalization. Improved electronic systems for managing therapeutic interchange and medication reconciliation may be valuable. PMID:29049325

Types of Possible Survey Errors in Estimates Published in the Weekly Natural Gas Storage Report

EIA Publications

2016-01-01

This document lists types of potential errors in EIA estimates published in the WNGSR. Survey errors are an unavoidable aspect of data collection. Error is inherent in all collected data, regardless of the source of the data and the care and competence of data collectors. The type and extent of error depends on the type and characteristics of the survey.

Texture analysis improves level set segmentation of the anterior abdominal wall

DOE Office of Scientific and Technical Information (OSTI.GOV)

Xu, Zhoubing; Allen, Wade M.; Baucom, Rebeccah B.

2013-12-15

Purpose: The treatment of ventral hernias (VH) has been a challenging problem for medical care. Repair of these hernias is fraught with failure; recurrence rates ranging from 24% to 43% have been reported, even with the use of biocompatible mesh. Currently, computed tomography (CT) is used to guide intervention through expert, but qualitative, clinical judgments, notably, quantitative metrics based on image-processing are not used. The authors propose that image segmentation methods to capture the three-dimensional structure of the abdominal wall and its abnormalities will provide a foundation on which to measure geometric properties of hernias and surrounding tissues and, therefore,more » to optimize intervention.Methods: In this study with 20 clinically acquired CT scans on postoperative patients, the authors demonstrated a novel approach to geometric classification of the abdominal. The authors’ approach uses a texture analysis based on Gabor filters to extract feature vectors and follows a fuzzy c-means clustering method to estimate voxelwise probability memberships for eight clusters. The memberships estimated from the texture analysis are helpful to identify anatomical structures with inhomogeneous intensities. The membership was used to guide the level set evolution, as well as to derive an initial start close to the abdominal wall.Results: Segmentation results on abdominal walls were both quantitatively and qualitatively validated with surface errors based on manually labeled ground truth. Using texture, mean surface errors for the outer surface of the abdominal wall were less than 2 mm, with 91% of the outer surface less than 5 mm away from the manual tracings; errors were significantly greater (2–5 mm) for methods that did not use the texture.Conclusions: The authors’ approach establishes a baseline for characterizing the abdominal wall for improving VH care. Inherent texture patterns in CT scans are helpful to the tissue classification, and texture analysis can improve the level set segmentation around the abdominal region.« less

Management strategies to effect change in intensive care units: lessons from the world of business. Part I. Targeting quality improvement initiatives.

PubMed

Gershengorn, Hayley B; Kocher, Robert; Factor, Phillip

2014-02-01

The business community has developed strategies to ensure the quality of the goods or services they produce and to improve the management of multidisciplinary work teams. With modification, many of these techniques can be imported into intensive care units (ICUs) to improve clinical operations and patient safety. In Part I of a three-part ATS Seminar series, we argue for adopting business management strategies in ICUs and set forth strategies for targeting selected quality improvement initiatives. These tools are relevant to health care today as focus is placed on limiting low-value care and measuring, reporting, and improving quality. In the ICU, the complexity of illness and the need to standardize processes make these tools even more appealing. Herein, we highlight four techniques to help prioritize initiatives. First, the "80/20 rule" mandates focus on the few (20%) interventions likely to drive the majority (80%) of improvement. Second, benchmarking--a process of comparison with peer units or institutions--is essential to identifying areas of strength and weakness. Third, root cause analyses, in which structured retrospective reviews of negative events are performed, can be used to identify and fix systems errors. Finally, failure mode and effects analysis--a process aimed at prospectively identifying potential sources of error--allows for systems fixes to be instituted in advance to prevent negative outcomes. These techniques originated in fields other than health care, yet adoption has and can help ICU managers prioritize issues for quality improvement.

A Comparison of Two Commercial Volumetry Software Programs in the Analysis of Pulmonary Ground-Glass Nodules: Segmentation Capability and Measurement Accuracy

PubMed Central

Kim, Hyungjin; Lee, Sang Min; Lee, Hyun-Ju; Goo, Jin Mo

2013-01-01

Objective To compare the segmentation capability of the 2 currently available commercial volumetry software programs with specific segmentation algorithms for pulmonary ground-glass nodules (GGNs) and to assess their measurement accuracy. Materials and Methods In this study, 55 patients with 66 GGNs underwent unenhanced low-dose CT. GGN segmentation was performed by using 2 volumetry software programs (LungCARE, Siemens Healthcare; LungVCAR, GE Healthcare). Successful nodule segmentation was assessed visually and morphologic features of GGNs were evaluated to determine factors affecting segmentation by both types of software. In addition, the measurement accuracy of the software programs was investigated by using an anthropomorphic chest phantom containing simulated GGNs. Results The successful nodule segmentation rate was significantly higher in LungCARE (90.9%) than in LungVCAR (72.7%) (p = 0.012). Vascular attachment was a negatively influencing morphologic feature of nodule segmentation for both software programs. As for measurement accuracy, mean relative volume measurement errors in nodules ≥ 10 mm were 14.89% with LungCARE and 19.96% with LungVCAR. The mean relative attenuation measurement errors in nodules ≥ 10 mm were 3.03% with LungCARE and 5.12% with LungVCAR. Conclusion LungCARE shows significantly higher segmentation success rates than LungVCAR. Measurement accuracy of volume and attenuation of GGNs is acceptable in GGNs ≥ 10 mm by both software programs. PMID:23901328

Long-term care physical environments--effect on medication errors.

PubMed

Mahmood, Atiya; Chaudhury, Habib; Gaumont, Alana; Rust, Tiana

2012-01-01

Few studies examine physical environmental factors and their effects on staff health, effectiveness, work errors and job satisfaction. To address this gap, this study aims to examine environmental features and their role in medication and nursing errors in long-term care facilities. A mixed methodological strategy was used. Data were collected via focus groups, observing medication preparation and administration, and a nursing staff survey in four facilities. The paper reveals that, during the medication preparation phase, physical design, such as medication room layout, is a major source of potential errors. During medication administration, social environment is more likely to contribute to errors. Interruptions, noise and staff shortages were particular problems. The survey's relatively small sample size needs to be considered when interpreting the findings. Also, actual error data could not be included as existing records were incomplete. The study offers several relatively low-cost recommendations to help staff reduce medication errors. Physical environmental factors are important when addressing measures to reduce errors. The findings of this study underscore the fact that the physical environment's influence on the possibility of medication errors is often neglected. This study contributes to the scarce empirical literature examining the relationship between physical design and patient safety.

Patient identification errors are common in a simulated setting.

PubMed

Henneman, Philip L; Fisher, Donald L; Henneman, Elizabeth A; Pham, Tuan A; Campbell, Megan M; Nathanson, Brian H

2010-06-01

We evaluate the frequency and accuracy of health care workers verifying patient identity before performing common tasks. The study included prospective, simulated patient scenarios with an eye-tracking device that showed where the health care workers looked. Simulations involved nurses administering an intravenous medication, technicians labeling a blood specimen, and clerks applying an identity band. Participants were asked to perform their assigned task on 3 simulated patients, and the third patient had a different date of birth and medical record number than the identity information on the artifact label specific to the health care workers' task. Health care workers were unaware that the focus of the study was patient identity. Sixty-one emergency health care workers participated--28 nurses, 16 technicians, and 17 emergency service associates--in 183 patient scenarios. Sixty-one percent of health care workers (37/61) caught the identity error (61% nurses, 94% technicians, 29% emergency service associates). Thirty-nine percent of health care workers (24/61) performed their assigned task on the wrong patient (39% nurses, 6% technicians, 71% emergency service associates). Eye-tracking data were available for 73% of the patient scenarios (133/183). Seventy-four percent of health care workers (74/100) failed to match the patient to the identity band (87% nurses, 49% technicians). Twenty-seven percent of health care workers (36/133) failed to match the artifact to the patient or the identity band before performing their task (33% nurses, 9% technicians, 33% emergency service associates). Fifteen percent (5/33) of health care workers who completed the steps to verify patient identity on the patient with the identification error still failed to recognize the error. Wide variation exists among health care workers verifying patient identity before performing everyday tasks. Education, process changes, and technology are needed to improve the frequency and accuracy of patient identification. Copyright (c) 2009. Published by Mosby, Inc.

The Impact of Incident Disclosure Behaviors on Medical Malpractice Claims.

PubMed

Giraldo, Priscila; Sato, Luke; Castells, Xavier

2017-06-30

To provide preliminary estimates of incident disclosure behaviors on medical malpractice claims. We conducted a descriptive analysis of data on medical malpractice claims obtained from the Controlled Risk Insurance Company and Risk Management Foundation of Harvard Medical Institutions (Cambridge, Massachusetts) between 2012 and 2013 (n = 434). The characteristics of disclosure and apology after medical errors were analyzed. Of 434 medical malpractice claims, 4.6% (n = 20) medical errors had been disclosed to the patient at the time of the error, and 5.9% (n = 26) had been followed by disclosure and apology. The highest number of disclosed injuries occurred in 2011 (23.9%; n = 11) and 2012 (34.8%; n = 16). There was no incremental increase during the financial years studied (2012-2013). The mean age of informed patients was 52.96 years, 58.7 % of the patients were female, and 52.2% were inpatients. Of the disclosed errors, 26.1% led to an adverse reaction, and 17.4% were fatal. The cause of disclosed medical error was improper surgical performance in 17.4% (95% confidence interval, 6.4-28.4). Disclosed medical errors were classified as medium severity in 67.4%. No apology statement was issued in 54.5% of medical errors classified as high severity. At the health-care centers studied, when a claim followed a medical error, providers infrequently disclosed medical errors or apologized to the patient or relatives. Most of the medical errors followed by disclosure and apology were classified as being of high and medium severity. No changes were detected in the volume of lawsuits over time.

Identification of factors associated with diagnostic error in primary care.

PubMed

Minué, Sergio; Bermúdez-Tamayo, Clara; Fernández, Alberto; Martín-Martín, José Jesús; Benítez, Vivian; Melguizo, Miguel; Caro, Araceli; Orgaz, María José; Prados, Miguel Angel; Díaz, José Enrique; Montoro, Rafael

2014-05-12

Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason's taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician's initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians' perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process.

Identification of factors associated with diagnostic error in primary care

PubMed Central

2014-01-01

Background Missed, delayed or incorrect diagnoses are considered to be diagnostic errors. The aim of this paper is to describe the methodology of a study to analyse cognitive aspects of the process by which primary care (PC) physicians diagnose dyspnoea. It examines the possible links between the use of heuristics, suboptimal cognitive acts and diagnostic errors, using Reason’s taxonomy of human error (slips, lapses, mistakes and violations). The influence of situational factors (professional experience, perceived overwork and fatigue) is also analysed. Methods Cohort study of new episodes of dyspnoea in patients receiving care from family physicians and residents at PC centres in Granada (Spain). With an initial expected diagnostic error rate of 20%, and a sampling error of 3%, 384 episodes of dyspnoea are calculated to be required. In addition to filling out the electronic medical record of the patients attended, each physician fills out 2 specially designed questionnaires about the diagnostic process performed in each case of dyspnoea. The first questionnaire includes questions on the physician’s initial diagnostic impression, the 3 most likely diagnoses (in order of likelihood), and the diagnosis reached after the initial medical history and physical examination. It also includes items on the physicians’ perceived overwork and fatigue during patient care. The second questionnaire records the confirmed diagnosis once it is reached. The complete diagnostic process is peer-reviewed to identify and classify the diagnostic errors. The possible use of heuristics of representativeness, availability, and anchoring and adjustment in each diagnostic process is also analysed. Each audit is reviewed with the physician responsible for the diagnostic process. Finally, logistic regression models are used to determine if there are differences in the diagnostic error variables based on the heuristics identified. Discussion This work sets out a new approach to studying the diagnostic decision-making process in PC, taking advantage of new technologies which allow immediate recording of the decision-making process. PMID:24884984

Complications: acknowledging, managing, and coping with human error.

PubMed

Helo, Sevann; Moulton, Carol-Anne E

2017-08-01

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

Complications: acknowledging, managing, and coping with human error

PubMed Central

Moulton, Carol-Anne E.

2017-01-01

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions. PMID:28904910

Clinical review: The hospital of the future - building intelligent environments to facilitate safe and effective acute care delivery

PubMed Central

2012-01-01

The translation of knowledge into rational care is as essential and pressing a task as the development of new diagnostic or therapeutic devices, and is arguably more important. The emerging science of health care delivery has identified the central role of human factor ergonomics in the prevention of medical error, omission, and waste. Novel informatics and systems engineering strategies provide an excellent opportunity to improve the design of acute care delivery. In this article, future hospitals are envisioned as organizations built around smart environments that facilitate consistent delivery of effective, equitable, and error-free care focused on patient-centered rather than provider-centered outcomes. PMID:22546172

Patient safety challenges in a case study hospital--of relevance for transfusion processes?

PubMed

Aase, Karina; Høyland, Sindre; Olsen, Espen; Wiig, Siri; Nilsen, Stein Tore

2008-10-01

The paper reports results from a research project with the objective of studying patient safety, and relates the finding to safety issues within transfusion medicine. The background is an increased focus on undesired events related to diagnosis, medication, and patient treatment in general in the healthcare sector. The study is designed as a case study within a regional Norwegian hospital conducting specialised health care services. The study includes multiple methods such as interviews, document analysis, analysis of error reports, and a questionnaire survey. Results show that the challenges for improved patient safety, based on employees' perceptions, are hospital management support, reporting of accidents/incidents, and collaboration across hospital units. Several of these generic safety challenges are also found to be of relevance for a hospital's transfusion service. Positive patient safety factors are identified as teamwork within hospital units, a non-punitive response to errors, and unit manager's actions promoting safety.

A Case Study on Improving Intensive Care Unit (ICU) Services Reliability: By Using Process Failure Mode and Effects Analysis (PFMEA)

PubMed Central

Yousefinezhadi, Taraneh; Jannesar Nobari, Farnaz Attar; Goodari, Faranak Behzadi; Arab, Mohammad

2016-01-01

Introduction: In any complex human system, human error is inevitable and shows that can’t be eliminated by blaming wrong doers. So with the aim of improving Intensive Care Units (ICU) reliability in hospitals, this research tries to identify and analyze ICU’s process failure modes at the point of systematic approach to errors. Methods: In this descriptive research, data was gathered qualitatively by observations, document reviews, and Focus Group Discussions (FGDs) with the process owners in two selected ICUs in Tehran in 2014. But, data analysis was quantitative, based on failures’ Risk Priority Number (RPN) at the base of Failure Modes and Effects Analysis (FMEA) method used. Besides, some causes of failures were analyzed by qualitative Eindhoven Classification Model (ECM). Results: Through FMEA methodology, 378 potential failure modes from 180 ICU activities in hospital A and 184 potential failures from 99 ICU activities in hospital B were identified and evaluated. Then with 90% reliability (RPN≥100), totally 18 failures in hospital A and 42 ones in hospital B were identified as non-acceptable risks and then their causes were analyzed by ECM. Conclusions: Applying of modified PFMEA for improving two selected ICUs’ processes reliability in two different kinds of hospitals shows that this method empowers staff to identify, evaluate, prioritize and analyze all potential failure modes and also make them eager to identify their causes, recommend corrective actions and even participate in improving process without feeling blamed by top management. Moreover, by combining FMEA and ECM, team members can easily identify failure causes at the point of health care perspectives. PMID:27157162

Thinly disguised contempt: a barrier to excellence.

PubMed

Brown-Stewart, P

1987-04-01

Many elements in contemporary leadership and management convey contempt for employees. "Thinly disguised contempt," a concept introduced by Peters and Austin in A Passion For Excellence, explains many barriers to the achievement of excellence in corporations across disciplines. Health care executives and managers can learn from the errors of corporate management and avoid replicating these errors in the health care industry.

Reducing Cognitive Skill Decay and Diagnostic Error: Theory-Based Practices for Continuing Education in Health Care

ERIC Educational Resources Information Center

Weaver, Sallie J.; Newman-Toker, David E.; Rosen, Michael A.

2012-01-01

Missed, delayed, or wrong diagnoses can have a severe impact on patients, providers, and the entire health care system. One mechanism implicated in such diagnostic errors is the deterioration of cognitive diagnostic skills that are used rarely or not at all over a prolonged period of time. Existing evidence regarding maintenance of effective…

Resident Physicians' Clinical Training and Error Rate: The Roles of Autonomy, Consultation, and Familiarity with the Literature

ERIC Educational Resources Information Center

Naveh, Eitan; Katz-Navon, Tal; Stern, Zvi

2015-01-01

Resident physicians' clinical training poses unique challenges for the delivery of safe patient care. Residents face special risks of involvement in medical errors since they have tremendous responsibility for patient care, yet they are novice practitioners in the process of learning and mastering their profession. The present study explores…

Wireless clinical alerts and patient outcomes in the surgical intensive care unit.

PubMed

Major, Kevin; Shabot, M Michael; Cunneen, Scott

2002-12-01

Errors in medicine have gained public interest since the Institute of Medicine published its 1999 report on this subject. Although errors of commission are frequently cited, errors of omission can be equally serious. A computerized surgical intensive care unit (SICU) information system when coupled to an event-driven alerting engine has the potential to reduce errors of omission for critical intensive care unit events. Automated alerts and patient outcomes were prospectively collected for all patients admitted to a tertiary-care SICU for a 2-year period. During the study period 3,973 patients were admitted to the SICU and received 13,608 days of care. A total of 15,066 alert pages were sent including alerts for physiologic condition (6,163), laboratory data (4,951), blood gas (3,774), drug allergy (130), and toxic drug levels (48). Admission Simplified Acute Physiology Score and Acute Physiology and Chronic Health Evaluation II score, SICU lengths of stay, and overall mortality rates were significantly higher in patients who triggered the alerting system. Patients triggering the alert paging system were 49.4 times more likely to die in the SICU compared with patients who did not generate an alert. Even after transfer to floor care the patients who triggered the alerting system were 5.7 times more likely to die in the hospital. An alert page identifies patients who will stay in the SICU longer and have a significantly higher chance of death compared with patients who do not trigger the alerting system.

Principles of cost-effective resource allocation in health care organizations.

PubMed

Weinstein, M C

1990-01-01

Cost-effectiveness analysis (CEA) is a method of economic evaluation that can be used to assess the efficiency with which health care technologies use limited resources to produce health outputs. However, inconsistencies in the way that such ratios are constructed often lead to misleading conclusions when CEAs are compared. Some of these inconsistencies, such as failure to discount or to calculate incremental ratios correctly, reflect analytical errors that, if corrected, would resolve the inconsistencies. Others reflect fundamental differences in the viewpoint of the analysis. The perspectives of different decision-making entities can properly lead to different items in the numerator and denominator of the cost-effectiveness (C/E) ratio. Producers and consumers of CEA need to be more conscious of the perspectives of analysis, so that C/E comparisons from a given perspective are based upon a common understanding of the elements that are properly included.

Questioning care at the end of life.

PubMed

Ruopp, Patricia; Good, Mary-Jo Delvecchio; Lakoma, Matthew; Gadmer, Nina M; Arnold, Robert M; Block, Susan D

2005-06-01

The goal of the larger study was to explore physicians' emotional responses to the death of their patients; this study analyzed a subset of physician transcripts to elucidate the construct of questioning care, which emerged from the larger study. To analyzes how physicians question care-expressing concern, unease, or uncertainty about treatment decisions and practices, errors, or adverse events-as they attend dying patients. Retrospective interview study of physicians caring for randomly selected deaths on the medical service of a major academic teaching hospital, using qualitative and quantitative measures. SETTING, SUBJECTS: 188 attendings, residents, and interns on the internal medical services of two academic medical centers were part of the larger study. A subsample of 75 physician narratives was selected for qualitative data analysis for this study. Qualitative measures included open-ended questions eliciting physicians' stories of the most recent and a most emotionally powerful patient death they have experienced. Grounded theory was used to analyze physician narratives. Quantitative instruments measured physician attitudes toward end-of-life care and responses to the most recent and most emotional patient death. Physicians question care more frequently in most emotional deaths (42%) than in most recent deaths (34%). Physicians question communication with patients and families and within medical teams, medical judgment and technique, standards of practice, and high-risk treatments, often assigning responsibility for medical management they perceive as inappropriate, futile, overly aggressive, or mistakes in judgment and technique. Responsibility ranges from the distal (the culture of medicine) to the proximal (personal). Frustration, guilt, and anger are more frequently expressed in these narratives when care is questioned. A typology of questioning care emerged from these physicians' narratives that parallels and reflects recent and classic research on medical error and the culture of medicine. Physicians' questions about care can contribute to designing training experiences for residents and to improving the quality of systems that affect patients' experiences at life's end and physicians' experiences in caring for dying patients.

Managerial process improvement: a lean approach to eliminating medication delivery.

PubMed

Hussain, Aftab; Stewart, LaShonda M; Rivers, Patrick A; Munchus, George

2015-01-01

Statistical evidence shows that medication errors are a major cause of injuries that concerns all health care oganizations. Despite all the efforts to improve the quality of care, the lack of understanding and inability of management to design a robust system that will strategically target those factors is a major cause of distress. The paper aims to discuss these issues. Achieving optimum organizational performance requires two key variables; work process factors and human performance factors. The approach is that healthcare administrators must take in account both variables in designing a strategy to reduce medication errors. However, strategies that will combat such phenomena require that managers and administrators understand the key factors that are causing medication delivery errors. The authors recommend that healthcare organizations implement the Toyota Production System (TPS) combined with human performance improvement (HPI) methodologies to eliminate medication delivery errors in hospitals. Despite all the efforts to improve the quality of care, there continues to be a lack of understanding and the ability of management to design a robust system that will strategically target those factors associated with medication errors. This paper proposes a solution to an ambiguous workflow process using the TPS combined with the HPI system.

Using Organization Risk Analyzer (ORA) to Explore the Relationship of Nursing Unit Communication to Patient Safety and Quality Outcomes

PubMed Central

Effken, Judith A.; Carley, Kathleen M.; Gephart, Sheila; Verran, Joyce A.; Bianchi, Denise; Reminga, Jeff; Brewer, Barbara

2011-01-01

Purpose We used Organization Risk Analyzer (ORA), a dynamic network analysis tool, to identify patient care unit communication patterns associated with patient safety and quality outcomes. Although ORA had previously had limited use in healthcare, we felt it could effectively model communication on patient care units. Methods Using a survey methodology, we collected communication network data from nursing staff on seven patient care units on two different days. Patient outcome data were collected via a separate survey. Results of the staff survey were used to represent the communication networks for each unit in ORA. We then used ORA's analysis capability to generate communication metrics for each unit. ORA's visualization capability was used to better understand the metrics. Results We identified communication patterns that correlated with two safety (falls and medication errors) and five quality (e.g., symptom management, complex self care, and patient satisfaction) outcome measures. Communication patterns differed substantially by shift. Conclusion The results demonstrate the utility of ORA for healthcare research and the relationship of nursing unit communication patterns to patient safety and quality outcomes. PMID:21536492

Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit.

PubMed

Booth, Rachelle; Sturgess, Emma; Taberner-Stokes, Alison; Peters, Mark

2012-11-01

To establish the baseline prescribing error rate in a tertiary paediatric intensive care unit (PICU) and to determine the impact of a zero tolerance prescribing (ZTP) policy incorporating a dedicated prescribing area and daily feedback of prescribing errors. A prospective, non-blinded, observational study was undertaken in a 12-bed tertiary PICU over a period of 134 weeks. Baseline prescribing error data were collected on weekdays for all patients for a period of 32 weeks, following which the ZTP policy was introduced. Daily error feedback was introduced after a further 12 months. Errors were sub-classified as 'clinical', 'non-clinical' and 'infusion prescription' errors and the effects of interventions considered separately. The baseline combined prescribing error rate was 892 (95 % confidence interval (CI) 765-1,019) errors per 1,000 PICU occupied bed days (OBDs), comprising 25.6 % clinical, 44 % non-clinical and 30.4 % infusion prescription errors. The combined interventions of ZTP plus daily error feedback were associated with a reduction in the combined prescribing error rate to 447 (95 % CI 389-504) errors per 1,000 OBDs (p < 0.0001), an absolute risk reduction of 44.5 % (95 % CI 40.8-48.0 %). Introduction of the ZTP policy was associated with a significant decrease in clinical and infusion prescription errors, while the introduction of daily error feedback was associated with a significant reduction in non-clinical prescribing errors. The combined interventions of ZTP and daily error feedback were associated with a significant reduction in prescribing errors in the PICU, in line with Department of Health requirements of a 40 % reduction within 5 years.

Medicine and aviation: a review of the comparison.

PubMed

Randell, R

2003-01-01

This paper aims to understand the nature of medical error in highly technological environments and argues that a comparison with aviation can blur its real understanding. This study is a comparative study between the notion of error in health care and aviation based on the author's own ethnographic study in intensive care units and findings from the research literature on errors in aviation. Failures in the use of medical technology are common. In attempts to understand the area of medical error, much attention has focused on how we can learn from aviation. This paper argues that such a comparison is not always useful, on the basis that (i) the type of work and technology is very different in the two domains; (ii) different issues are involved in training and procurement; and (iii) attitudes to error vary between the domains. Therefore, it is necessary to look closely at the subject of medical error and resolve those questions left unanswered by the lessons of aviation.

Database Design to Ensure Anonymous Study of Medical Errors: A Report from the ASIPS collaborative

PubMed Central

Pace, Wilson D.; Staton, Elizabeth W.; Higgins, Gregory S.; Main, Deborah S.; West, David R.; Harris, Daniel M.

2003-01-01

Medical error reporting systems are important information sources for designing strategies to improve the safety of health care. Applied Strategies for Improving Patient Safety (ASIPS) is a multi-institutional, practice-based research project that collects and analyzes data on primary care medical errors and develops interventions to reduce error. The voluntary ASIPS Patient Safety Reporting System captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports; however, concerns exist about the confidentiality of those reports should the database be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error. The authors present the design and implementation of a database and administrative system that reduce this risk, facilitate research, and maintain near anonymity of the events, practices, and clinicians. PMID:12925548

Fully anisotropic goal-oriented mesh adaptation for 3D steady Euler equations

NASA Astrophysics Data System (ADS)

Loseille, A.; Dervieux, A.; Alauzet, F.

2010-04-01

This paper studies the coupling between anisotropic mesh adaptation and goal-oriented error estimate. The former is very well suited to the control of the interpolation error. It is generally interpreted as a local geometric error estimate. On the contrary, the latter is preferred when studying approximation errors for PDEs. It generally involves non local error contributions. Consequently, a full and strong coupling between both is hard to achieve due to this apparent incompatibility. This paper shows how to achieve this coupling in three steps. First, a new a priori error estimate is proved in a formal framework adapted to goal-oriented mesh adaptation for output functionals. This estimate is based on a careful analysis of the contributions of the implicit error and of the interpolation error. Second, the error estimate is applied to the set of steady compressible Euler equations which are solved by a stabilized Galerkin finite element discretization. A goal-oriented error estimation is derived. It involves the interpolation error of the Euler fluxes weighted by the gradient of the adjoint state associated with the observed functional. Third, rewritten in the continuous mesh framework, the previous estimate is minimized on the set of continuous meshes thanks to a calculus of variations. The optimal continuous mesh is then derived analytically. Thus, it can be used as a metric tensor field to drive the mesh adaptation. From a numerical point of view, this method is completely automatic, intrinsically anisotropic, and does not depend on any a priori choice of variables to perform the adaptation. 3D examples of steady flows around supersonic and transsonic jets are presented to validate the current approach and to demonstrate its efficiency.

Patient Safety Incidents and Nursing Workload 1

PubMed Central

Carlesi, Katya Cuadros; Padilha, Kátia Grillo; Toffoletto, Maria Cecília; Henriquez-Roldán, Carlos; Juan, Monica Andrea Canales

2017-01-01

ABSTRACT Objective: to identify the relationship between the workload of the nursing team and the occurrence of patient safety incidents linked to nursing care in a public hospital in Chile. Method: quantitative, analytical, cross-sectional research through review of medical records. The estimation of workload in Intensive Care Units (ICUs) was performed using the Therapeutic Interventions Scoring System (TISS-28) and for the other services, we used the nurse/patient and nursing assistant/patient ratios. Descriptive univariate and multivariate analysis were performed. For the multivariate analysis we used principal component analysis and Pearson correlation. Results: 879 post-discharge clinical records and the workload of 85 nurses and 157 nursing assistants were analyzed. The overall incident rate was 71.1%. It was found a high positive correlation between variables workload (r = 0.9611 to r = 0.9919) and rate of falls (r = 0.8770). The medication error rates, mechanical containment incidents and self-removal of invasive devices were not correlated with the workload. Conclusions: the workload was high in all units except the intermediate care unit. Only the rate of falls was associated with the workload. PMID:28403334

Analysis and Evaluation of the Reconfigured Exponential Troposphere Model (ETM)

DTIC Science & Technology

2006-05-10

Southeast Asia, Northeast Asia, Amazon Rainforest , Sahara Desert, and Australia) have been selected for comparison based on their climate extremes, such as...of Appendix B Appendix B presents angle errors for the Middle East, the Amazon Rainforest , Northeast Asia, and Southeast Asia using the ETM Monthly...and calibration should be carefully implemented in this region for RF communication, application, and operation. For the Amazon Rainforest region, data

Development and Psychometric Analysis of a Nurses’ Attitudes and Skills Safety Scale: Initial Results

PubMed Central

Armstrong, Gail E.; Dietrich, Mary; Norman, Linda; Barnsteiner, Jane; Mion, Lorraine

2016-01-01

Health care organizations have incorporated updated safety principles in the analysis of errors and in norms and standards. Yet no research exists that assesses bedside nurses’ perceived skills or attitudes toward updated safety concepts. The aims of this study were to develop a scale assessing nurses’ perceived skills and attitudes toward updated safety concepts, determine content validity, and examine internal consistency of the scale and subscales. Understanding nurses’ perceived skills and attitudes about safety concepts can be used in targeting strategies to enhance their safety practices. PMID:27479518

Development and Psychometric Analysis of a Nurses' Attitudes and Skills Safety Scale: Initial Results.

PubMed

Armstrong, Gail E; Dietrich, Mary; Norman, Linda; Barnsteiner, Jane; Mion, Lorraine

Health care organizations have incorporated updated safety principles in the analysis of errors and in norms and standards. Yet no research exists that assesses bedside nurses' perceived skills or attitudes toward updated safety concepts. The aims of this study were to develop a scale assessing nurses' perceived skills and attitudes toward updated safety concepts, determine content validity, and examine internal consistency of the scale and subscales. Understanding nurses' perceived skills and attitudes about safety concepts can be used in targeting strategies to enhance their safety practices.

Barriers to medication error reporting among hospital nurses.

PubMed

Rutledge, Dana N; Retrosi, Tina; Ostrowski, Gary

2018-03-01

The study purpose was to report medication error reporting barriers among hospital nurses, and to determine validity and reliability of an existing medication error reporting barriers questionnaire. Hospital medication errors typically occur between ordering of a medication to its receipt by the patient with subsequent staff monitoring. To decrease medication errors, factors surrounding medication errors must be understood; this requires reporting by employees. Under-reporting can compromise patient safety by disabling improvement efforts. This 2017 descriptive study was part of a larger workforce engagement study at a faith-based Magnet ® -accredited community hospital in California (United States). Registered nurses (~1,000) were invited to participate in the online survey via email. Reported here are sample demographics (n = 357) and responses to the 20-item medication error reporting barriers questionnaire. Using factor analysis, four factors that accounted for 67.5% of the variance were extracted. These factors (subscales) were labelled Fear, Cultural Barriers, Lack of Knowledge/Feedback and Practical/Utility Barriers; each demonstrated excellent internal consistency. The medication error reporting barriers questionnaire, originally developed in long-term care, demonstrated good validity and excellent reliability among hospital nurses. Substantial proportions of American hospital nurses (11%-48%) considered specific factors as likely reporting barriers. Average scores on most barrier items were categorised "somewhat unlikely." The highest six included two barriers concerning the time-consuming nature of medication error reporting and four related to nurses' fear of repercussions. Hospitals need to determine the presence of perceived barriers among nurses using questionnaires such as the medication error reporting barriers and work to encourage better reporting. Barriers to medication error reporting make it less likely that nurses will report medication errors, especially errors where patient harm is not apparent or where an error might be hidden. Such under-reporting impedes collection of accurate medication error data and prevents hospitals from changing harmful practices. © 2018 John Wiley & Sons Ltd.

Endodontic Procedural Errors: Frequency, Type of Error, and the Most Frequently Treated Tooth.

PubMed

Yousuf, Waqas; Khan, Moiz; Mehdi, Hasan

2015-01-01

Introduction. The aim of this study is to determine the most common endodontically treated tooth and the most common error produced during treatment and to note the association of particular errors with particular teeth. Material and Methods. Periapical radiographs were taken of all the included teeth and were stored and assessed using DIGORA Optime. Teeth in each group were evaluated for presence or absence of procedural errors (i.e., overfill, underfill, ledge formation, perforations, apical transportation, and/or instrument separation) and the most frequent tooth to undergo endodontic treatment was also noted. Results. A total of 1748 root canal treated teeth were assessed, out of which 574 (32.8%) contained a procedural error. Out of these 397 (22.7%) were overfilled, 155 (8.9%) were underfilled, 16 (0.9%) had instrument separation, and 7 (0.4%) had apical transportation. The most frequently treated tooth was right permanent mandibular first molar (11.3%). The least commonly treated teeth were the permanent mandibular third molars (0.1%). Conclusion. Practitioners should show greater care to maintain accuracy of the working length throughout the procedure, as errors in length accounted for the vast majority of errors and special care should be taken when working on molars.

Statistical process control methods allow the analysis and improvement of anesthesia care.

PubMed

Fasting, Sigurd; Gisvold, Sven E

2003-10-01

Quality aspects of the anesthetic process are reflected in the rate of intraoperative adverse events. The purpose of this report is to illustrate how the quality of the anesthesia process can be analyzed using statistical process control methods, and exemplify how this analysis can be used for quality improvement. We prospectively recorded anesthesia-related data from all anesthetics for five years. The data included intraoperative adverse events, which were graded into four levels, according to severity. We selected four adverse events, representing important quality and safety aspects, for statistical process control analysis. These were: inadequate regional anesthesia, difficult emergence from general anesthesia, intubation difficulties and drug errors. We analyzed the underlying process using 'p-charts' for statistical process control. In 65,170 anesthetics we recorded adverse events in 18.3%; mostly of lesser severity. Control charts were used to define statistically the predictable normal variation in problem rate, and then used as a basis for analysis of the selected problems with the following results: Inadequate plexus anesthesia: stable process, but unacceptably high failure rate; Difficult emergence: unstable process, because of quality improvement efforts; Intubation difficulties: stable process, rate acceptable; Medication errors: methodology not suited because of low rate of errors. By applying statistical process control methods to the analysis of adverse events, we have exemplified how this allows us to determine if a process is stable, whether an intervention is required, and if quality improvement efforts have the desired effect.

Iranian family caregivers' challenges and issues in caring of multiple sclerosis patients: A descriptive explorative qualitative study.

PubMed

Masoudi, Reza; Abedi, Heidar Ali; Abedi, Parvin; Mohammadianinejad, Seyed Ehsan

2014-07-01

The broad spectrum of problems caused by multiple sclerosis (MS) imposes heavy responsibility to caregivers in caring of their patients. Therefore, they encounter many issues and challenges in this situation. The purpose of this study was to explore the experiences and challenges of MS family caregivers. A qualitative design, based on a thematic analysis approach, was used to reach the study aim. Data were collected and analyzed concurrently through in-depth unstructured interviews, field notes, and observations that were held with 23 participants (14 family caregivers and 9 MS patients) at two referral centers in Ahvaz, Iran. THREE MAJOR THEMES WERE EXTRACTED FROM THE ANALYSIS OF THE TRANSCRIPTS: "emotional exhaustion of caregivers," "uncertain atmosphere of caring," and "insularity care." The first theme consisted of three subthemes: "stressful atmosphere of caring," "conflict and animism," and "continuing distress affecting the caregiver." The second theme consisted of three subthemes: "unstable and complicacy of disease," "caring with trial and error," and "frequent hospitalization of patients," and the third theme consisted of two subthemes: "caring gap and disintegration" and "lack of sufficient support." This study will be useful to healthcare system for managing the challenges of MS patients' family caregivers. Improving the conditions and performance of family caregivers is crucial in order to provide high-quality care to people with MS.

Decrease in medical command errors with use of a "standing orders" protocol system.

PubMed

Holliman, C J; Wuerz, R C; Meador, S A

1994-05-01

The purpose of this study was to determine the physician medical command error rates and paramedic error rates after implementation of a "standing orders" protocol system for medical command. These patient-care error rates were compared with the previously reported rates for a "required call-in" medical command system (Ann Emerg Med 1992; 21(4):347-350). A secondary aim of the study was to determine if the on-scene time interval was increased by the standing orders system. Prospectively conducted audit of prehospital advanced life support (ALS) trip sheets was made at an urban ALS paramedic service with on-line physician medical command from three local hospitals. All ALS run sheets from the start time of the standing orders system (April 1, 1991) for a 1-year period ending on March 30, 1992 were reviewed as part of an ongoing quality assurance program. Cases were identified as nonjustifiably deviating from regional emergency medical services (EMS) protocols as judged by agreement of three physician reviewers (the same methodology as a previously reported command error study in the same ALS system). Medical command and paramedic errors were identified from the prehospital ALS run sheets and categorized. Two thousand one ALS runs were reviewed; 24 physician errors (1.2% of the 1,928 "command" runs) and eight paramedic errors (0.4% of runs) were identified. The physician error rate was decreased from the 2.6% rate in the previous study (P < .0001 by chi 2 analysis). The on-scene time interval did not increase with the "standing orders" system.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of technical errors and periapical lesions in a sample of endodontically treated teeth: a CBCT analysis.

PubMed

Nascimento, Eduarda Helena Leandro; Gaêta-Araujo, Hugo; Andrade, Maria Fernanda Silva; Freitas, Deborah Queiroz

2018-01-21

The aims of this study are to identify the most frequent technical errors in endodontically treated teeth and to determine which root canals were most often associated with those errors, as well as to relate endodontic technical errors and the presence of coronal restorations with periapical status by means of cone-beam computed tomography images. Six hundred eighteen endodontically treated teeth (1146 root canals) were evaluated for the quality of their endodontic treatment and for the presence of coronal restorations and periapical lesions. Each root canal was classified according to dental groups, and the endodontic technical errors were recorded. Chi-square's test and descriptive analyses were performed. Six hundred eighty root canals (59.3%) had periapical lesions. Maxillary molars and anterior teeth showed higher prevalence of periapical lesions (p < 0.05). Endodontic treatment quality and coronal restoration were associated with periapical status (p < 0.05). Underfilling was the most frequent technical error in all root canals, except for the second mesiobuccal root canal of maxillary molars and the distobuccal root canal of mandibular molars, which were non-filled in 78.4 and 30% of the cases, respectively. There is a high prevalence of apical radiolucencies, which increased in the presence of poor coronal restorations, endodontic technical errors, and when both conditions were concomitant. Underfilling was the most frequent technical error, followed by non-homogeneous and non-filled canals. Evaluation of endodontic treatment quality that considers every single root canal aims on warning dental practitioners of the prevalence of technical errors that could be avoided with careful treatment planning and execution.

Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission (medicines reconciliation).

PubMed

Karnon, Jonathan; Campbell, Fiona; Czoski-Murray, Carolyn

2009-04-01

Medication errors can lead to preventable adverse drug events (pADEs) that have significant cost and health implications. Errors often occur at care interfaces, and various interventions have been devised to reduce medication errors at the point of admission to hospital. The aim of this study is to assess the incremental costs and effects [measured as quality adjusted life years (QALYs)] of a range of such interventions for which evidence of effectiveness exists. A previously published medication errors model was adapted to describe the pathway of errors occurring at admission through to the occurrence of pADEs. The baseline model was populated using literature-based values, and then calibrated to observed outputs. Evidence of effects was derived from a systematic review of interventions aimed at preventing medication error at hospital admission. All five interventions, for which evidence of effectiveness was identified, are estimated to be extremely cost-effective when compared with the baseline scenario. Pharmacist-led reconciliation intervention has the highest expected net benefits, and a probability of being cost-effective of over 60% by a QALY value of pound10 000. The medication errors model provides reasonably strong evidence that some form of intervention to improve medicines reconciliation is a cost-effective use of NHS resources. The variation in the reported effectiveness of the few identified studies of medication error interventions illustrates the need for extreme attention to detail in the development of interventions, but also in their evaluation and may justify the primary evaluation of more than one specification of included interventions.

Anatomy of emotion: a 3D study of facial mimicry.

PubMed

Ferrario, V F; Sforza, C

2007-01-01

Alterations in facial motion severely impair the quality of life and social interaction of patients, and an objective grading of facial function is necessary. A method for the non-invasive detection of 3D facial movements was developed. Sequences of six standardized facial movements (maximum smile; free smile; surprise with closed mouth; surprise with open mouth; right side eye closure; left side eye closure) were recorded in 20 healthy young adults (10 men, 10 women) using an optoelectronic motion analyzer. For each subject, 21 cutaneous landmarks were identified by 2-mm reflective markers, and their 3D movements during each facial animation were computed. Three repetitions of each expression were recorded (within-session error), and four separate sessions were used (between-session error). To assess the within-session error, the technical error of the measurement (random error, TEM) was computed separately for each sex, movement and landmark. To assess the between-session repeatability, the standard deviation among the mean displacements of each landmark (four independent sessions) was computed for each movement. TEM for the single landmarks ranged between 0.3 and 9.42 mm (intrasession error). The sex- and movement-related differences were statistically significant (two-way analysis of variance, p=0.003 for sex comparison, p=0.009 for the six movements, p<0.001 for the sex x movement interaction). Among four different (independent) sessions, the left eye closure had the worst repeatability, the right eye closure had the best one; the differences among various movements were statistically significant (one-way analysis of variance, p=0.041). In conclusion, the current protocol demonstrated a sufficient repeatability for a future clinical application. Great care should be taken to assure a consistent marker positioning in all the subjects.

Improving Histopathology Laboratory Productivity: Process Consultancy and A3 Problem Solving.

PubMed

Yörükoğlu, Kutsal; Özer, Erdener; Alptekin, Birsen; Öcal, Cem

2017-01-01

The ISO 17020 quality program has been run in our pathology laboratory for four years to establish an action plan for correction and prevention of identified errors. In this study, we aimed to evaluate the errors that we could not identify through ISO 17020 and/or solve by means of process consulting. Process consulting is carefully intervening in a group or team to help it to accomplish its goals. The A3 problem solving process was run under the leadership of a 'workflow, IT and consultancy manager'. An action team was established consisting of technical staff. A root cause analysis was applied for target conditions, and the 6-S method was implemented for solution proposals. Applicable proposals were activated and the results were rated by six-sigma analysis. Non-applicable proposals were reported to the laboratory administrator. A mislabelling error was the most complained issue triggering all pre-analytical errors. There were 21 non-value added steps grouped in 8 main targets on the fish bone graphic (transporting, recording, moving, individual, waiting, over-processing, over-transaction and errors). Unnecessary redundant requests, missing slides, archiving issues, redundant activities, and mislabelling errors were proposed to be solved by improving visibility and fixing spaghetti problems. Spatial re-organization, organizational marking, re-defining some operations, and labeling activities raised the six sigma score from 24% to 68% for all phases. Operational transactions such as implementation of a pathology laboratory system was suggested for long-term improvement. Laboratory management is a complex process. Quality control is an effective method to improve productivity. Systematic checking in a quality program may not always find and/or solve the problems. External observation may reveal crucial indicators about the system failures providing very simple solutions.

Recognizing and managing errors of cognitive underspecification.

PubMed

Duthie, Elizabeth A

2014-03-01

James Reason describes cognitive underspecification as incomplete communication that creates a knowledge gap. Errors occur when an information mismatch occurs in bridging that gap with a resulting lack of shared mental models during the communication process. There is a paucity of studies in health care examining this cognitive error and the role it plays in patient harm. The goal of the following case analyses is to facilitate accurate recognition, identify how it contributes to patient harm, and suggest appropriate management strategies. Reason's human error theory is applied in case analyses of errors of cognitive underspecification. Sidney Dekker's theory of human incident investigation is applied to event investigation to facilitate identification of this little recognized error. Contributory factors leading to errors of cognitive underspecification include workload demands, interruptions, inexperienced practitioners, and lack of a shared mental model. Detecting errors of cognitive underspecification relies on blame-free listening and timely incident investigation. Strategies for interception include two-way interactive communication, standardization of communication processes, and technological support to ensure timely access to documented clinical information. Although errors of cognitive underspecification arise at the sharp end with the care provider, effective management is dependent upon system redesign that mitigates the latent contributory factors. Cognitive underspecification is ubiquitous whenever communication occurs. Accurate identification is essential if effective system redesign is to occur.

Continuing Care

MedlinePlus

... Care Obesity at Midlife May Speed Alzheimer’s Onset Hello from my mom Easing the Behavior Problems of ... Managers Continuing Care FOR MORE ARTICLES CLICK HERE Hello from my mom Common Estate Planning Errors Alzheimer’s ...

Analyzing thematic maps and mapping for accuracy

USGS Publications Warehouse

Rosenfield, G.H.

1982-01-01

Two problems which exist while attempting to test the accuracy of thematic maps and mapping are: (1) evaluating the accuracy of thematic content, and (2) evaluating the effects of the variables on thematic mapping. Statistical analysis techniques are applicable to both these problems and include techniques for sampling the data and determining their accuracy. In addition, techniques for hypothesis testing, or inferential statistics, are used when comparing the effects of variables. A comprehensive and valid accuracy test of a classification project, such as thematic mapping from remotely sensed data, includes the following components of statistical analysis: (1) sample design, including the sample distribution, sample size, size of the sample unit, and sampling procedure; and (2) accuracy estimation, including estimation of the variance and confidence limits. Careful consideration must be given to the minimum sample size necessary to validate the accuracy of a given. classification category. The results of an accuracy test are presented in a contingency table sometimes called a classification error matrix. Usually the rows represent the interpretation, and the columns represent the verification. The diagonal elements represent the correct classifications. The remaining elements of the rows represent errors by commission, and the remaining elements of the columns represent the errors of omission. For tests of hypothesis that compare variables, the general practice has been to use only the diagonal elements from several related classification error matrices. These data are arranged in the form of another contingency table. The columns of the table represent the different variables being compared, such as different scales of mapping. The rows represent the blocking characteristics, such as the various categories of classification. The values in the cells of the tables might be the counts of correct classification or the binomial proportions of these counts divided by either the row totals or the column totals from the original classification error matrices. In hypothesis testing, when the results of tests of multiple sample cases prove to be significant, some form of statistical test must be used to separate any results that differ significantly from the others. In the past, many analyses of the data in this error matrix were made by comparing the relative magnitudes of the percentage of correct classifications, for either individual categories, the entire map or both. More rigorous analyses have used data transformations and (or) two-way classification analysis of variance. A more sophisticated step of data analysis techniques would be to use the entire classification error matrices using the methods of discrete multivariate analysis or of multiviariate analysis of variance.

Bayesian assessment of overtriage and undertriage at a level I trauma centre.

PubMed

DiDomenico, Paul B; Pietzsch, Jan B; Paté-Cornell, M Elisabeth

2008-07-13

We analysed the trauma triage system at a specific level I trauma centre to assess rates of over- and undertriage and to support recommendations for system improvements. The triage process is designed to estimate the severity of patient injury and allocate resources accordingly, with potential errors of overestimation (overtriage) consuming excess resources and underestimation (undertriage) potentially leading to medical errors.We first modelled the overall trauma system using risk analysis methods to understand interdependencies among the actions of the participants. We interviewed six experienced trauma surgeons to obtain their expert opinion of the over- and undertriage rates occurring in the trauma centre. We then assessed actual over- and undertriage rates in a random sample of 86 trauma cases collected over a six-week period at the same centre. We employed Bayesian analysis to quantitatively combine the data with the prior probabilities derived from expert opinion in order to obtain posterior distributions. The results were estimates of overtriage and undertriage in 16.1 and 4.9% of patients, respectively. This Bayesian approach, which provides a quantitative assessment of the error rates using both case data and expert opinion, provides a rational means of obtaining a best estimate of the system's performance. The overall approach that we describe in this paper can be employed more widely to analyse complex health care delivery systems, with the objective of reduced errors, patient risk and excess costs.

Prioritizing medication safety in care of people with cancer: clinicians’ views on main problems and solutions

PubMed Central

Car, Lorainne Tudor; Papachristou, Nikolaos; Urch, Catherine; Majeed, Azeem; Atun, Rifat; Car, Josip; Vincent, Charles

2017-01-01

Background Cancer care is liable to medication errors due to the complex nature of cancer treatment, the common presence of comorbidities and the involvement of a number of clinicians in cancer care. While the frequency of medication errors in cancer care has been reported, little is known about their causal factors and effective prevention strategies. With a unique insight into the main safety issues in cancer treatment, frontline staff can help close this gap. In this study, we aimed to identify medication safety priorities in cancer patient care according to clinicians in North West London using PRIORITIZE, a novel priority–setting approach. Methods The project steering group determined the scope, the context and the criteria for prioritization. We then invited North West London cancer care clinicians to identify and prioritize main causes for, and solutions to, medication errors in cancer care. Forty cancer care providers submitted their suggestions which were thematically synthesized into a composite list of 20 distinct problems and 22 solutions. A group of 26 clinicians from the initial cohort ranked the composite list of suggestions using predetermined criteria. Results The top ranked problems focused on patients’ poor understanding of treatments due to language or education difficulties, clinicians’ insufficient attention to patients’ psychological distress, and inadequate information sharing among health care providers. The top ranked solutions were provision of guidance to patients and their carers on what to do when unwell, pre–chemotherapy work–up for all patients and better staff training. Overall, clinicians considered improved communication between health care providers, quality assurance procedures (during prescription and monitoring stages) and patient education as key strategies for improving cancer medication safety. Prescribing stage was identified as the most vulnerable to medication safety threats. The highest ranked suggestions received the strongest agreement among the clinicians. Conclusions Clinician–identified priorities for reducing medication errors in cancer care addressed various aspects of cancer treatment. Our findings open up an opportunity to assess the congruence between health care professional suggestions, currently implemented patient safety policies and evidence base. PMID:28685047

Prioritizing medication safety in care of people with cancer: clinicians' views on main problems and solutions.

PubMed

Car, Lorainne Tudor; Papachristou, Nikolaos; Urch, Catherine; Majeed, Azeem; Atun, Rifat; Car, Josip; Vincent, Charles

2017-06-01

Cancer care is liable to medication errors due to the complex nature of cancer treatment, the common presence of comorbidities and the involvement of a number of clinicians in cancer care. While the frequency of medication errors in cancer care has been reported, little is known about their causal factors and effective prevention strategies. With a unique insight into the main safety issues in cancer treatment, frontline staff can help close this gap. In this study, we aimed to identify medication safety priorities in cancer patient care according to clinicians in North West London using PRIORITIZE, a novel priority-setting approach. The project steering group determined the scope, the context and the criteria for prioritization. We then invited North West London cancer care clinicians to identify and prioritize main causes for, and solutions to, medication errors in cancer care. Forty cancer care providers submitted their suggestions which were thematically synthesized into a composite list of 20 distinct problems and 22 solutions. A group of 26 clinicians from the initial cohort ranked the composite list of suggestions using predetermined criteria. The top ranked problems focused on patients' poor understanding of treatments due to language or education difficulties, clinicians' insufficient attention to patients' psychological distress, and inadequate information sharing among health care providers. The top ranked solutions were provision of guidance to patients and their carers on what to do when unwell, pre-chemotherapy work-up for all patients and better staff training. Overall, clinicians considered improved communication between health care providers, quality assurance procedures (during prescription and monitoring stages) and patient education as key strategies for improving cancer medication safety. Prescribing stage was identified as the most vulnerable to medication safety threats. The highest ranked suggestions received the strongest agreement among the clinicians. Clinician-identified priorities for reducing medication errors in cancer care addressed various aspects of cancer treatment. Our findings open up an opportunity to assess the congruence between health care professional suggestions, currently implemented patient safety policies and evidence base.

Health Equity and the Fallacy of Treating Causes of Population Health as if They Sum to 100.

PubMed

Krieger, Nancy

2017-04-01

Numerous examples exist in population health of work that erroneously forces the causes of health to sum to 100%. This is surprising. Clear refutations of this error extend back 80 years. Because public health analysis, action, and allocation of resources are ill served by faulty methods, I consider why this error persists. I first review several high-profile examples, including Doll and Peto's 1981 opus on the causes of cancer and its current interpretations; a 2015 high-publicity article in Science claiming that two thirds of cancer is attributable to chance; and the influential Web site "County Health Rankings & Roadmaps: Building a Culture of Health, County by County," whose model sums causes of health to equal 100%: physical environment (10%), social and economic factors (40%), clinical care (20%), and health behaviors (30%). Critical analysis of these works and earlier historical debates reveals that underlying the error of forcing causes of health to sum to 100% is the still dominant but deeply flawed view that causation can be parsed as nature versus nurture. Better approaches exist for tallying risk and monitoring efforts to reach health equity.

Health Equity and the Fallacy of Treating Causes of Population Health as if They Sum to 100%

PubMed Central

2017-01-01

Numerous examples exist in population health of work that erroneously forces the causes of health to sum to 100%. This is surprising. Clear refutations of this error extend back 80 years. Because public health analysis, action, and allocation of resources are ill served by faulty methods, I consider why this error persists. I first review several high-profile examples, including Doll and Peto’s 1981 opus on the causes of cancer and its current interpretations; a 2015 high-publicity article in Science claiming that two thirds of cancer is attributable to chance; and the influential Web site “County Health Rankings & Roadmaps: Building a Culture of Health, County by County,” whose model sums causes of health to equal 100%: physical environment (10%), social and economic factors (40%), clinical care (20%), and health behaviors (30%). Critical analysis of these works and earlier historical debates reveals that underlying the error of forcing causes of health to sum to 100% is the still dominant but deeply flawed view that causation can be parsed as nature versus nurture. Better approaches exist for tallying risk and monitoring efforts to reach health equity. PMID:28272952

Improvements to photometry. Part 1: Better estimation of derivatives in extinction and transformation equations

NASA Technical Reports Server (NTRS)

Young, Andrew T.

1988-01-01

Atmospheric extinction in wideband photometry is examined both analytically and through numerical simulations. If the derivatives that appear in the Stromgren-King theory are estimated carefully, it appears that wideband measurements can be transformed to outside the atmosphere with errors no greater than a millimagnitude. A numerical analysis approach is used to estimate derivatives of both the stellar and atmospheric extinction spectra, avoiding previous assumptions that the extinction follows a power law. However, it is essential to satify the requirements of the sampling theorem to keep aliasing errors small. Typically, this means that band separations cannot exceed half of the full width at half-peak response. Further work is needed to examine higher order effects, which may well be significant.

Medication error reduction and the use of PDA technology.

PubMed

Greenfield, Sue

2007-03-01

The purpose of this study was to determine whether nursing medication errors could be reduced and nursing care provided more efficiently using personal digital assistant (PDA) technology. The sample for this study consisted of junior and senior undergraduate baccalaureate nursing students. By self-selection of owning a PDA or not, students were placed in the PDA (experimental) group or the textbook (control) group, provided with a case study to read, and asked to answer six questions (i.e., three medication administration calculations and three clinical decisions based on medication administration). The analysis of collected data, calculated using a t test, revealed that the PDA group answered the six questions with greater accuracy and speed than did the textbook group.

Do Work Condition Interventions Affect Quality and Errors in Primary Care? Results from the Healthy Work Place Study.

PubMed

Linzer, Mark; Poplau, Sara; Brown, Roger; Grossman, Ellie; Varkey, Anita; Yale, Steven; Williams, Eric S; Hicks, Lanis; Wallock, Jill; Kohnhorst, Diane; Barbouche, Michael

2017-01-01

While primary care work conditions are associated with adverse clinician outcomes, little is known about the effect of work condition interventions on quality or safety. A cluster randomized controlled trial of 34 clinics in the upper Midwest and New York City. Primary care clinicians and their diabetic and hypertensive patients. Quality improvement projects to improve communication between providers, workflow design, and chronic disease management. Intervention clinics received brief summaries of their clinician and patient outcome data at baseline. We measured work conditions and clinician and patient outcomes both at baseline and 6-12 months post-intervention. Multilevel regression analyses assessed the impact of work condition changes on outcomes. Subgroup analyses assessed impact by intervention category. There were no significant differences in error reduction (19 % vs. 11 %, OR of improvement 1.84, 95 % CI 0.70, 4.82, p = 0.21) or quality of care improvement (19 % improved vs. 44 %, OR 0.62, 95 % CI 0.58, 1.21, p = 0.42) between intervention and control clinics. The conceptual model linking work conditions, provider outcomes, and error reduction showed significant relationships between work conditions and provider outcomes (p ≤ 0.001) and a trend toward a reduced error rate in providers with lower burnout (OR 1.44, 95 % CI 0.94, 2.23, p = 0.09). Few quality metrics, short time span, fewer clinicians recruited than anticipated. Work-life interventions improving clinician satisfaction and well-being do not necessarily reduce errors or improve quality. Longer, more focused interventions may be needed to produce meaningful improvements in patient care. ClinicalTrials.gov # NCT02542995.

The positive financial impact of using an Intensive Care Information System in a tertiary Intensive Care Unit.

PubMed

Levesque, Eric; Hoti, Emir; de La Serna, Sofia; Habouchi, Houssam; Ichai, Philippe; Saliba, Faouzi; Samuel, Didier; Azoulay, Daniel

2013-03-01

In the French healthcare system, the intensive care budget allocated is directly dependent on the activity level of the center. To evaluate this activity level, it is necessary to code the medical diagnoses and procedures performed on Intensive Care Unit (ICU) patients. The aim of this study was to evaluate the effects of using an Intensive Care Information System (ICIS) on the incidence of coding errors and its impact on the ICU budget allocated. Since 2005, the documentation on and monitoring of every patient admitted to our ICU has been carried out using an ICIS. However, the coding process was performed manually until 2008. This study focused on two periods: the period of manual coding (year 2007) and the period of computerized coding (year 2008) which covered a total of 1403 ICU patients. The time spent on the coding process, the rate of coding errors (defined as patients missed/not coded or wrongly identified as undergoing major procedure/s) and the financial impact were evaluated for these two periods. With computerized coding, the time per admission decreased significantly (from 6.8 ± 2.8 min in 2007 to 3.6 ± 1.9 min in 2008, p<0.001). Similarly, a reduction in coding errors was observed (7.9% vs. 2.2%, p<0.001). This decrease in coding errors resulted in a reduced difference between the potential and real ICU financial supplements obtained in the respective years (€194,139 loss in 2007 vs. a €1628 loss in 2008). Using specific computer programs improves the intensive process of manual coding by shortening the time required as well as reducing errors, which in turn positively impacts the ICU budget allocation. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Computerized physician order entry from a chief information officer perspective.

PubMed

Cotter, Carole M

2004-12-01

Designing and implementing a computerized physician order entry system in the critical care units of a large urban hospital system is an enormous undertaking. With their significant potential to improve health care and significantly reduce errors, the time for computerized physician order entry or physician order management systems is past due. Careful integrated planning is the key to success, requiring multidisciplinary teams at all levels of clinical and administrative management to work together. Articulated from the viewpoint of the Chief Information Officer of Lifespan, a not-for-profit hospital system in Rhode Island, the vision and strategy preceding the information technology plan, understanding the system's current state, the gap analysis between current and future state, and finally, building and implementing the information technology plan are described.

Communication in critical care environments: mobile telephones improve patient care.

PubMed

Soto, Roy G; Chu, Larry F; Goldman, Julian M; Rampil, Ira J; Ruskin, Keith J

2006-02-01

Most hospital policies prohibiting the use of wireless devices cite reports of disruption of medical equipment by cellular telephones. There have been no studies to determine whether mobile telephones may have a beneficial impact on safety. At the 2003 meeting of the American Society of Anesthesiologists 7878 surveys were distributed to attendees. The five-question survey polled anesthesiologists regarding modes of communication used in the operating room/intensive care unit and experience with communications delays and medical errors. Survey reliability was verified using test-retest analysis and proportion agreement in a convenience sample of 17 anesthesiologists. Four-thousand-eighteen responses were received. The test-retest reliability of the survey instrument was excellent (Kappa = 0.75; 95% confidence interval, 0.56-0.94). Sixty-five percent of surveyed anesthesiologists reported using pagers as their primary mode of communications, whereas only 17% used cellular telephones. Forty-five percent of respondents who use pagers reported delays in communications compared with 31% of cellular telephone users. Cellular telephone use by anesthesiologists is associated with a reduction in the risk of medical error or injury resulting from communication delay (relative risk = 0.78; 95% confidence interval, 0.6234-0.9649). The small risks of electromagnetic interference between mobile telephones and medical devices should be weighed against the potential benefits of improved communication.

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND... rates, which is defined as the percentage of cases with an error (expressed as the total number of cases with an error compared to the total number of cases); the percentage of cases with an improper payment...

A retrospective review of medical errors adjudicated in court between 2002 and 2012 in Spain.

PubMed

Giraldo, Priscila; Sato, Luke; Sala, María; Comas, Merce; Dywer, Kathy; Castells, Xavier

2016-02-01

This paper describes verdicts in court involving injury-producing medical errors in Spain. A descriptive analysis of 1041 closed court verdicts from Spain between January 2002 and December 2012. It was determined whether a medical error had occurred, and among those with medical error (n = 270), characteristics and results of litigation were analyzed. Data on litigation were obtained from the Thomson Reuters Aranzadi Westlaw databases. All verdicts involving health system were reviewed and classified according to the presence of medical error. Among those, contributory factors, medical specialty involved, health impact (death, disability and severity) and results of litigation (resolution, time to verdict and economic compensations) were described. Medical errors were involved in 25.9% of court verdicts. The cause of medical error was a diagnosis-related problem in 25.1% and surgical treatment in 22.2%, and Obstetrics-Gynecology was the most frequent involved specialty (21%). Most of them were of high severity (59.4%), one-third (32%) caused death. The average time interval between the occurrence of the error and the verdict was 7.8 years. The average indemnity payment was €239 505.24; the highest was psychiatry (€7 585 075.86) and the lowest was Emergency Medicine (€69 871.19). This study indicates that in Spain medical errors are common among verdicts involving the health system, most of them causing high-severity adverse outcomes. The interval between the medical error and the verdict is excessive, and there is a wide range of economic compensation. © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

Medication Errors

MedlinePlus

... at the health care provider's office, at the pharmacy, or at home. You can help prevent errors ... medicine and check to make sure that the pharmacy gave you the right medicine. Make sure that ...

Iatrogenic disease management: moderating medication errors and risks in a pharmacy benefit management environment.

PubMed

Nair, Vinit; Salmon, J Warren; Kaul, Alan F

2007-12-01

Disease Management (DM) programs have advanced to address costly chronic disease patterns in populations. This is in part due to the programs' significant clinical and economical value, coupled with interest by pharmaceutical manufacturers, managed care organizations, and pharmacy benefit management firms. While cost containment realizations for many such interventions have been less than anticipated, this article explores potentials in marrying Medication Error Risk Reduction into DM programs within managed care environments. Medication errors are an emergent serious problem now gaining attention in US health policy. They represent a failure within population-based health programs because they remain significant cost drivers. Therefore, medication errors should be addressed in an organized fashion, with DM being a worthy candidate for piggybacking such programs to achieve the best synergistic effects.

Cost-utility analysis of a preventive home visit program for older adults in Germany.

PubMed

Brettschneider, Christian; Luck, Tobias; Fleischer, Steffen; Roling, Gudrun; Beutner, Katrin; Luppa, Melanie; Behrens, Johann; Riedel-Heller, Steffi G; König, Hans-Helmut

2015-04-03

Most older adults want to live independently in a familiar environment instead of moving to a nursing home. Preventive home visits based on multidimensional geriatric assessment can be one strategy to support this preference and might additionally reduce health care costs, due to the avoidance of costly nursing home admissions. The purpose of this study was to analyse the cost-effectiveness of preventive home visits from a societal perspective in Germany. This study is part of a multi-centre, non-blinded, randomised controlled trial aiming at the reduction of nursing home admissions. Participants were older than 80 years and living at home. Up to three home visits were conducted to identify self-care deficits and risk factors, to present recommendations and to implement solutions. The control group received usual care. A cost-utility analysis using quality-adjusted life years (QALY) based on the EQ-5D was performed. Resource utilization was assessed by means of the interview version of a patient questionnaire. A cost-effectiveness acceptability curve controlled for prognostic variables was constructed and a sensitivity analysis to control for the influence of the mode of QALY calculation was performed. 278 individuals (intervention group: 133; control group: 145) were included in the analysis. During 18 months follow-up mean adjusted total cost (mean: +4,401 EUR; bootstrapped standard error: 3,019.61 EUR) and number of QALY (mean: 0.0061 QALY; bootstrapped standard error: 0.0388 QALY) were higher in the intervention group, but differences were not significant. For preventive home visits the probability of an incremental cost-effectiveness ratio <50,000 EUR per QALY was only 15%. The results were robust with respect to the mode of QALY calculation. The evaluated preventive home visits programme is unlikely to be cost-effective. Clinical Trials.gov Identifier: NCT00644826.

Hyper-Realistic, Team-Centered Fleet Surgical Team Training Provides Sustained Improvements in Performance.

PubMed

Hoang, Tuan N; Kang, Jeff; Siriratsivawong, Kris; LaPorta, Anthony; Heck, Amber; Ferraro, Jessica; Robinson, Douglas; Walsh, Jonathan

2016-01-01

The high-stress, fast-paced environment of combat casualty care relies on effective teamwork and communication which translates into quality patient care. A training course was developed for U.S. Navy Fleet Surgical Teams to address these aspects of patient care by emphasizing efficiency and appropriate patient care. An effective training course provides knowledge and skills to pass the course evaluation and sustain the knowledge and skills acquired over time. The course included classroom didactic hours, and hands-on simulation sessions. A pretest was administered before the course, a posttest upon completion, and a sustainment test 5 months following course completion. The evaluation process measured changes in patient time to disposition and critical errors made during patient care. Naval Base San Diego, with resuscitation and surgical simulations carried out within the shipboard medical spaces. United States Navy medical personnel including physicians of various specialties, corpsmen, nurses, and nurse anesthetists deploying aboard ships. Time to disposition improved significantly, 11 ± 3 minutes, from pretest to posttest, and critical errors improved by 4 ± 1 errors per encounter. From posttest to sustainment test, time to disposition increased by 3 ± 1, and critical errors decreased by 1 ± 1. This course showed value in improving teamwork and communication skills of participants, immediately upon completion of the course, and after 5 months had passed. Therefore, with ongoing sustainment activities within 6 months, this course can substantially improve trauma care provided by shipboard deployed Navy medical personnel to wounded service members. Published by Elsevier Inc.

Sustainability of protocolized handover of pediatric cardiac surgery patients to the intensive care unit.

PubMed

Chenault, Kristin; Moga, Michael-Alice; Shin, Minah; Petersen, Emily; Backer, Carl; De Oliveira, Gildasio S; Suresh, Santhanam

2016-05-01

Transfer of patient care among clinicians (handovers) is a common source of medical errors. While the immediate efficacy of these initiatives is well documented, sustainability of practice changes that results in better processes of care is largely understudied. The objective of the current investigation was to evaluate the sustainability of a protocolized handover process in pediatric patients from the operating room after cardiac surgery to the intensive care unit. This was a prospective study with direct observation assessment of handover performance conducted in the cardiac ICU (CICU) of a free-standing, tertiary care children's hospital in the United States. Patient transitions from the operating room to the CICU, including the verbal handoff, were directly observed by a single independent observer in all phases of the study. A checklist of key elements identified errors classified as: (1) technical, (2) information omissions, and (3) realized errors. Total number of errors was compared across the different times of the study (preintervention, postintervention, and the current sustainability phase). A total of 119 handovers were studied: 41 preintervention, 38 postintervention, and 40 in the current sustainability phase. The median [Interquartile range (IQR)] number of technical errors was significantly reduced in the sustainability phase compared to the preintervention and postintervention phase, 2 (1-3), 6 (5-7), and 2.5 (2-4), respectively P = 0.0001. Similarly, the median (IQR) number of verbal information omissions was also significantly reduced in the sustainability phase compared to the preintervention and postintervention phases, 1 (1-1), 4 (3-5) and 2 (1-3), respectively. We demonstrate sustainability of an improved handover process using a checklist in children being transferred to the intensive care unit after cardiac surgery. Standardized handover processes can be a sustainable strategy to improve patient safety after pediatric cardiac surgery. © 2016 John Wiley & Sons Ltd.

Evaluating physician performance at individualizing care: a pilot study tracking contextual errors in medical decision making.

PubMed

Weiner, Saul J; Schwartz, Alan; Yudkowsky, Rachel; Schiff, Gordon D; Weaver, Frances M; Goldberg, Julie; Weiss, Kevin B

2007-01-01

Clinical decision making requires 2 distinct cognitive skills: the ability to classify patients' conditions into diagnostic and management categories that permit the application of research evidence and the ability to individualize or-more specifically-to contextualize care for patients whose circumstances and needs require variation from the standard approach to care. The purpose of this study was to develop and test a methodology for measuring physicians' performance at contextualizing care and compare it to their performance at planning biomedically appropriate care. First, the authors drafted 3 cases, each with 4 variations, 3 of which are embedded with biomedical and/or contextual information that is essential to planning care. Once the cases were validated as instruments for assessing physician performance, 54 internal medicine residents were then presented with opportunities to make these preidentified biomedical or contextual errors, and data were collected on information elicitation and error making. The case validation process was successful in that, in the final iteration, the physicians who received the contextual variant of cases proposed an alternate plan of care to those who received the baseline variant 100% of the time. The subsequent piloting of these validated cases unmasked previously unmeasured differences in physician performance at contextualizing care. The findings, which reflect the performance characteristics of the study population, are presented. This pilot study demonstrates a methodology for measuring physician performance at contextualizing care and illustrates the contribution of such information to an overall assessment of physician practice.

[Malpractice Claims Against Pediatricians - Analysis of Expert Testimonies from the Medical Service of Health Insurance Companies Between 2000 and 2014].

PubMed

Steinhauer, Heiko; Holzschuh, Joachim; Böhler, Thomas

2017-11-01

Background In Germany, few data are available on medical malpractice claims against pediatricians. On behalf of Statutory Health Insurance Companies their Medical Service (MDK) regularly offers expert testimony in case of allegations during pediatric treatment. Methods Analysis of 374 written pediatric testimonies, documented between September 1st, 2000 and August 31st, 2014. Results 193 allegations against pediatricians were analysed separately for each sector of care (35% concerning outpatients, 28% normal inpatients, and 37% patients treated in an intensive care unit, ICU). Outpatient care led more frequently to malpractice claims regarding diagnosis, most often in the case of dysplasia of the hip (n=6), meningitis (n=5), and pneumonia (n=4). In inpatients, allegations regarding treatment errors were more common and frequently associated with extravasation injury (n=7), as well as periventricular leukomalacia (n=7), sepsis (=6), and intraventricular haemorrhage (n=4) in newborn infants on ICUs. Expert testimony confirmed allegations in 43% of the outpatients, 22% of the normal inpatients and 38% of the ICU patients. Discussion and conclusion The frequency of pediatric malpractice claims seems to depend primarily on the pattern of utilization of pediatric care services. Diagnosis-related constellations leading to malpractice claims in Germany are well-known internationally. Case analysis according to medical care sectors allows comprehensible conclusions for risk management. © Georg Thieme Verlag KG Stuttgart · New York.

Error, blame, and the law in health care--an antipodean perspective.

PubMed

Runciman, William B; Merry, Alan F; Tito, Fiona

2003-06-17

Patients are frequently harmed by problems arising from the health care process itself. Addressing these problems requires understanding the role of errors, violations, and system failures in their genesis. Problem-solving is inhibited by a tendency to blame those involved, often inappropriately. This has been aggravated by the need to attribute blame before compensation can be obtained through tort and the human failing of attributing blame simply because there has been a serious outcome. Blaming and punishing for errors that are made by well-intentioned people working in the health care system drives the problem of iatrogenic harm underground and alienates people who are best placed to prevent such problems from recurring. On the other hand, failure to assign blame when it is due is also undesirable and erodes trust in the medical profession. Understanding the distinction between blameworthy behavior and inevitable human errors and appreciating the systemic factors that underlie most failures in complex systems are essential for the response to a harmed patient to be informed, fair, and effective in improving safety. It is important to meet society's needs to blame and exact retribution when appropriate. However, this should not be a prerequisite for compensation, which should be appropriately structured, fair, timely, and, ideally, properly funded as an intrinsic part of health care and social security systems.

Paediatric in-patient prescribing errors in Malaysia: a cross-sectional multicentre study.

PubMed

Khoo, Teik Beng; Tan, Jing Wen; Ng, Hoong Phak; Choo, Chong Ming; Bt Abdul Shukor, Intan Nor Chahaya; Teh, Siao Hean

2017-06-01

Background There is a lack of large comprehensive studies in developing countries on paediatric in-patient prescribing errors in different settings. Objectives To determine the characteristics of in-patient prescribing errors among paediatric patients. Setting General paediatric wards, neonatal intensive care units and paediatric intensive care units in government hospitals in Malaysia. Methods This is a cross-sectional multicentre study involving 17 participating hospitals. Drug charts were reviewed in each ward to identify the prescribing errors. All prescribing errors identified were further assessed for their potential clinical consequences, likely causes and contributing factors. Main outcome measures Incidence, types, potential clinical consequences, causes and contributing factors of the prescribing errors. Results The overall prescribing error rate was 9.2% out of 17,889 prescribed medications. There was no significant difference in the prescribing error rates between different types of hospitals or wards. The use of electronic prescribing had a higher prescribing error rate than manual prescribing (16.9 vs 8.2%, p < 0.05). Twenty eight (1.7%) prescribing errors were deemed to have serious potential clinical consequences and 2 (0.1%) were judged to be potentially fatal. Most of the errors were attributed to human factors, i.e. performance or knowledge deficit. The most common contributing factors were due to lack of supervision or of knowledge. Conclusions Although electronic prescribing may potentially improve safety, it may conversely cause prescribing errors due to suboptimal interfaces and cumbersome work processes. Junior doctors need specific training in paediatric prescribing and close supervision to reduce prescribing errors in paediatric in-patients.

Cost-benefit analysis: newborn screening for inborn errors of metabolism in Lebanon.

PubMed

Khneisser, I; Adib, S; Assaad, S; Megarbane, A; Karam, P

2015-12-01

Few countries in the Middle East-North Africa region have adopted national newborn screening for inborn errors of metabolism by tandem mass spectrometry (MS/MS). We aimed to evaluate the cost-benefit of newborn screening for such disorders in Lebanon, as a model for other developing countries in the region. Average costs of expected care for inborn errors of metabolism cases as a group, between ages 0 and 18, early and late diagnosed, were calculated from 2007 to 2013. The monetary value of early detection using MS/MS was compared with that of clinical "late detection", including cost of diagnosis and hospitalizations. During this period, 126000 newborns were screened. Incidence of detected cases was 1/1482, which can be explained by high consanguinity rates in Lebanon. A reduction by half of direct cost of care, reaching on average 31,631 USD per detected case was shown. This difference more than covers the expense of starting a newborn screening programme. Although this model does not take into consideration the indirect benefits of the better quality of life of those screened early, it can be argued that direct and indirect costs saved through early detection of these disorders are important enough to justify universal publicly-funded screening, especially in developing countries with high consanguinity rates, as shown through this data from Lebanon. © The Author(s) 2015.

Frequency and types of the medication errors in an academic emergency department in Iran: The emergent need for clinical pharmacy services in emergency departments.

PubMed

Zeraatchi, Alireza; Talebian, Mohammad-Taghi; Nejati, Amir; Dashti-Khavidaki, Simin

2013-07-01

Emergency departments (EDs) are characterized by simultaneous care of multiple patients with various medical conditions. Due to a large number of patients with complex diseases, speed and complexity of medication use, working in under-staffing and crowded environment, medication errors are commonly perpetrated by emergency care providers. This study was designed to evaluate the incidence of medication errors among patients attending to an ED in a teaching hospital in Iran. In this cross-sectional study, a total of 500 patients attending to ED were randomly assessed for incidence and types of medication errors. Some factors related to medication errors such as working shift, weekdays and schedule of the educational program of trainee were also evaluated. Nearly, 22% of patients experienced at least one medication error. The rate of medication errors were 0.41 errors per patient and 0.16 errors per ordered medication. The frequency of medication errors was higher in men, middle age patients, first weekdays, night-time work schedules and the first semester of educational year of new junior emergency medicine residents. More than 60% of errors were prescription errors by physicians and the remaining were transcription or administration errors by nurses. More than 35% of the prescribing errors happened during the selection of drug dose and frequency. The most common medication errors by nurses during the administration were omission error (16.2%) followed by unauthorized drug (6.4%). Most of the medication errors happened for anticoagulants and thrombolytics (41.2%) followed by antimicrobial agents (37.7%) and insulin (7.4%). In this study, at least one-fifth of the patients attending to ED experienced medication errors resulting from multiple factors. More common prescription errors happened during ordering drug dose and frequency. More common administration errors included dug omission or unauthorized drug.

Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem.

PubMed

Perez, Bianca; Knych, Stephen A; Weaver, Sallie J; Liberman, Aaron; Abel, Eileen M; Oetjen, Dawn; Wan, Thomas T H

2014-03-01

The issues of medical errors and medical malpractice have stimulated significant interest in establishing transparency in health care, in other words, ensuring that medical professionals formally report medical errors and disclose related outcomes to patients and families. However, research has amply shown that transparency is not a universal practice among physicians. A review of the literature was carried out using the search terms "transparency," "patient safety," "disclosure," "medical error," "error reporting," "medical malpractice," "doctor-patient relationship," and "physician" to find articles describing physician barriers to transparency. The current literature underscores that a complex Web of factors influence physician reluctance to engage in transparency. Specifically, 4 domains of barriers emerged from this analysis: intrapersonal, interpersonal, institutional, and societal. Transparency initiatives will require vigorous, interdisciplinary efforts to address the systemic and pervasive nature of the problem. Several ethical and social-psychological barriers suggest that medical schools and hospitals should collaborate to establish continuity in education and ensure that knowledge acquired in early education is transferred into long-term learning. At the institutional level, practical and cultural barriers suggest the creation of supportive learning environments and private discussion forums where physicians can seek moral support in the aftermath of an error. To overcome resistance to culture transformation, incremental change should be considered, for example, replacing arcane transparency policies and complex reporting mechanisms with clear, user-friendly guidelines.

Case-related factors affecting cutting errors of the proximal tibia in total knee arthroplasty assessed by computer navigation.

PubMed

Tsukeoka, Tadashi; Tsuneizumi, Yoshikazu; Yoshino, Kensuke; Suzuki, Mashiko

2018-05-01

The aim of this study was to determine factors that contribute to bone cutting errors of conventional instrumentation for tibial resection in total knee arthroplasty (TKA) as assessed by an image-free navigation system. The hypothesis is that preoperative varus alignment is a significant contributory factor to tibial bone cutting errors. This was a prospective study of a consecutive series of 72 TKAs. The amount of the tibial first-cut errors with reference to the planned cutting plane in both coronal and sagittal planes was measured by an image-free computer navigation system. Multiple regression models were developed with the amount of tibial cutting error in the coronal and sagittal planes as dependent variables and sex, age, disease, height, body mass index, preoperative alignment, patellar height (Insall-Salvati ratio) and preoperative flexion angle as independent variables. Multiple regression analysis showed that sex (male gender) (R = 0.25 p = 0.047) and preoperative varus alignment (R = 0.42, p = 0.001) were positively associated with varus tibial cutting errors in the coronal plane. In the sagittal plane, none of the independent variables was significant. When performing TKA in varus deformity, careful confirmation of the bone cutting surface should be performed to avoid varus alignment. The results of this study suggest technical considerations that can help a surgeon achieve more accurate component placement. IV.

Overview of medical errors and adverse events

PubMed Central

2012-01-01

Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures. PMID:22339769

Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital.

PubMed

Michaelson, M; Walsh, E; Bradley, C P; McCague, P; Owens, R; Sahm, L J

2017-08-01

Prescribing error may result in adverse clinical outcomes leading to increased patient morbidity, mortality and increased economic burden. Many errors occur during transitional care as patients move between different stages and settings of care. To conduct a review of medication information and identify prescribing error among an adult population in an urban hospital. Retrospective review of medication information was conducted. Part 1: an audit of discharge prescriptions which assessed: legibility, compliance with legal requirements, therapeutic errors (strength, dose and frequency) and drug interactions. Part 2: A review of all sources of medication information (namely pre-admission medication list, drug Kardex, discharge prescription, discharge letter) for 15 inpatients to identify unintentional prescription discrepancies, defined as: "undocumented and/or unjustified medication alteration" throughout the hospital stay. Part 1: of the 5910 prescribed items; 53 (0.9%) were deemed illegible. Of the controlled drug prescriptions 11.1% (n = 167) met all the legal requirements. Therapeutic errors occurred in 41% of prescriptions (n = 479) More than 1 in 5 patients (21.9%) received a prescription containing a drug interaction. Part 2: 175 discrepancies were identified across all sources of medication information; of which 78 were deemed unintentional. Of these: 10.2% (n = 8) occurred at the point of admission, whereby 76.9% (n = 60) occurred at the point of discharge. The study identified the time of discharge as a point at which prescribing errors are likely to occur. This has implications for patient safety and provider work load in both primary and secondary care.

Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration.

PubMed

Flynn, Fran; Evanish, Julie Q; Fernald, Josephine M; Hutchinson, Dawn E; Lefaiver, Cheryl

2016-08-01

Because of the high frequency of interruptions during medication administration, the effectiveness of strategies to limit interruptions during medication administration has been evaluated in numerous quality improvement initiatives in an effort to reduce medication administration errors. To evaluate the effectiveness of evidence-based strategies to limit interruptions during scheduled, peak medication administration times in 3 progressive cardiac care units (PCCUs). A secondary aim of the project was to evaluate the impact of limiting interruptions on medication errors. The percentages of interruptions and medication errors before and after implementation of evidence-based strategies to limit interruptions were measured by using direct observations of nurses on 2 PCCUs. Nurses in a third PCCU served as a comparison group. Interruptions (P < .001) and medication errors (P = .02) decreased significantly in 1 PCCU after implementation of evidence-based strategies to limit interruptions. Avoidable interruptions decreased 83% in PCCU1 and 53% in PCCU2 after implementation of the evidence-based strategies. Implementation of evidence-based strategies to limit interruptions in PCCUs decreases avoidable interruptions and promotes patient safety. ©2016 American Association of Critical-Care Nurses.

Two Cultures in Modern Science and Technology: For Safety and Validity Does Medicine Have to Update?

PubMed

Becker, Robert E

2016-01-11

Two different scientific cultures go unreconciled in modern medicine. Each culture accepts that scientific knowledge and technologies are vulnerable to and easily invalidated by methods and conditions of acquisition, interpretation, and application. How these vulnerabilities are addressed separates the 2 cultures and potentially explains medicine's difficulties eradicating errors. A traditional culture, dominant in medicine, leaves error control in the hands of individual and group investigators and practitioners. A competing modern scientific culture accepts errors as inevitable, pernicious, and pervasive sources of adverse events throughout medical research and patient care too malignant for individuals or groups to control. Error risks to the validity of scientific knowledge and safety in patient care require systemwide programming able to support a culture in medicine grounded in tested, continually updated, widely promulgated, and uniformly implemented standards of practice for research and patient care. Experiences from successes in other sciences and industries strongly support the need for leadership from the Institute of Medicine's recommended Center for Patient Safely within the Federal Executive branch of government.

My copilot is a nurse--using crew resource management in the OR.

PubMed

Powell, Stephen M; Hill, Ruth Kimberly

2006-01-01

Crew resource management (CRM) has been used for more than 20 years in the aviation industry to teach individual error countermeasures by developing nontechnical (ie, cognitive, social) skills based on the observed traits of successful individuals and crews. The health care industry began to investigate aviation CRM after the Institute of Medicine's report, To Err is Human: Building a Safer Health System, recommended that medicine adopt aviation's approach to safety and error management. Initial results of implementing CRM in health care arenas have demonstrated reduced adverse outcomes, reduced errors, reduced length of stay, improved nurse retention, and changed attitudes and behaviors toward teamwork.

Decreasing patient identification band errors by standardizing processes.

PubMed

Walley, Susan Chu; Berger, Stephanie; Harris, Yolanda; Gallizzi, Gina; Hayes, Leslie

2013-04-01

Patient identification (ID) bands are an essential component in patient ID. Quality improvement methodology has been applied as a model to reduce ID band errors although previous studies have not addressed standardization of ID bands. Our specific aim was to decrease ID band errors by 50% in a 12-month period. The Six Sigma DMAIC (define, measure, analyze, improve, and control) quality improvement model was the framework for this study. ID bands at a tertiary care pediatric hospital were audited from January 2011 to January 2012 with continued audits to June 2012 to confirm the new process was in control. After analysis, the major improvement strategy implemented was standardization of styles of ID bands and labels. Additional interventions included educational initiatives regarding the new ID band processes and disseminating institutional and nursing unit data. A total of 4556 ID bands were audited with a preimprovement ID band error average rate of 9.2%. Significant variation in the ID band process was observed, including styles of ID bands. Interventions were focused on standardization of the ID band and labels. The ID band error rate improved to 5.2% in 9 months (95% confidence interval: 2.5-5.5; P < .001) and was maintained for 8 months. Standardization of ID bands and labels in conjunction with other interventions resulted in a statistical decrease in ID band error rates. This decrease in ID band error rates was maintained over the subsequent 8 months.

Error identification, disclosure, and reporting: practice patterns of three emergency medicine provider types.

PubMed

Hobgood, Cherri; Xie, Jipan; Weiner, Bryan; Hooker, James

2004-02-01

To gather preliminary data on how the three major types of emergency medicine (EM) providers, physicians, nurses (RNs), and out-of-hospital personnel (EMTs), differ in error identification, disclosure, and reporting. A convenience sample of emergency department (ED) providers completed a brief survey designed to evaluate error frequency, disclosure, and reporting practices as well as error-based discussion and educational activities. One hundred sixteen subjects participated: 41 EMTs (35%), 33 RNs (28%), and 42 physicians (36%). Forty-five percent of EMTs, 56% of RNs, and 21% of physicians identified no clinical errors during the preceding year. When errors were identified, physicians learned of them via dialogue with RNs (58%), patients (13%), pharmacy (35%), and attending physicians (35%). For known errors, all providers were equally unlikely to inform the team caring for the patient. Disclosure to patients was limited and varied by provider type (19% EMTs, 23% RNs, and 74% physicians). Disclosure education was rare, with

A comparison of endoscopic localization error rate between operating surgeons and referring endoscopists in colorectal cancer.

PubMed

Azin, Arash; Saleh, Fady; Cleghorn, Michelle; Yuen, Andrew; Jackson, Timothy; Okrainec, Allan; Quereshy, Fayez A

2017-03-01

Colonoscopy for colorectal cancer (CRC) has a localization error rate as high as 21 %. Such errors can have substantial clinical consequences, particularly in laparoscopic surgery. The primary objective of this study was to compare accuracy of tumor localization at initial endoscopy performed by either the operating surgeon or non-operating referring endoscopist. All patients who underwent surgical resection for CRC at a large tertiary academic hospital between January 2006 and August 2014 were identified. The exposure of interest was the initial endoscopist: (1) surgeon who also performed the definitive operation (operating surgeon group); and (2) referring gastroenterologist or general surgeon (referring endoscopist group). The outcome measure was localization error, defined as a difference in at least one anatomic segment between initial endoscopy and final operative location. Multivariate logistic regression was used to explore the association between localization error rate and the initial endoscopist. A total of 557 patients were included in the study; 81 patients in the operating surgeon cohort and 476 patients in the referring endoscopist cohort. Initial diagnostic colonoscopy performed by the operating surgeon compared to referring endoscopist demonstrated statistically significant lower intraoperative localization error rate (1.2 vs. 9.0 %, P = 0.016); shorter mean time from endoscopy to surgery (52.3 vs. 76.4 days, P = 0.015); higher tattoo localization rate (32.1 vs. 21.0 %, P = 0.027); and lower preoperative repeat endoscopy rate (8.6 vs. 40.8 %, P < 0.001). Initial endoscopy performed by the operating surgeon was protective against localization error on both univariate analysis, OR 7.94 (95 % CI 1.08-58.52; P = 0.016), and multivariate analysis, OR 7.97 (95 % CI 1.07-59.38; P = 0.043). This study demonstrates that diagnostic colonoscopies performed by an operating surgeon are independently associated with a lower localization error rate. Further research exploring the factors influencing localization accuracy and why operating surgeons have lower error rates relative to non-operating endoscopists is necessary to understand differences in care.

Empirical mono- versus combination antibiotic therapy in adult intensive care patients with severe sepsis - A systematic review with meta-analysis and trial sequential analysis.

PubMed

Sjövall, Fredrik; Perner, Anders; Hylander Møller, Morten

2017-04-01

To assess benefits and harms of empirical mono- vs. combination antibiotic therapy in adult patients with severe sepsis in the intensive care unit (ICU). We performed a systematic review according to the Cochrane Collaboration methodology, including meta-analysis, risk of bias assessment and trial sequential analysis (TSA). We included randomised clinical trials (RCT) assessing empirical mono-antibiotic therapy versus a combination of two or more antibiotics in adult ICU patients with severe sepsis. We exclusively assessed patient-important outcomes, including mortality. Two reviewers independently evaluated studies for inclusion, extracted data, and assessed risk of bias. Risk ratios (RRs) with 95% confidence intervals (CIs) were estimated and the risk of random errors was assessed by TSA. Thirteen RCTs (n = 2633) were included; all were judged as having high risk of bias. Carbapenems were the most frequently used mono-antibiotic (8 of 13 trials). There was no difference in mortality (RR 1.11, 95% CI 0.95-1.29; p = 0.19) or in any other patient-important outcomes between mono- vs. combination therapy. In TSA of mortality, the Z-curve reached the futility area, indicating that a 20% relative risk difference in mortality may be excluded between the two groups. For the other outcomes, TSA indicated lack of data and high risk of random errors. This systematic review of RCTs with meta-analysis and TSA demonstrated no differences in mortality or other patient-important outcomes between empirical mono- vs. combination antibiotic therapy in adult ICU patients with severe sepsis. The quantity and quality of data was low without firm evidence for benefit or harm of combination therapy. Copyright © 2016 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

The Iowa new practice model: Advancing technician roles to increase pharmacists' time to provide patient care services.

PubMed

Andreski, Michael; Myers, Megan; Gainer, Kate; Pudlo, Anthony

Determine the effects of an 18-month pilot project using tech-check-tech in 7 community pharmacies on 1) rate of dispensing errors not identified during refill prescription final product verification; 2) pharmacist workday task composition; and 3) amount of patient care services provided and the reimbursement status of those services. Pretest-posttest quasi-experimental study where baseline and study periods were compared. Pharmacists and pharmacy technicians in 7 community pharmacies in Iowa. The outcome measures were 1) percentage of technician verified refill prescriptions where dispensing errors were not identified on final product verification; 2) percentage of time spent by pharmacists in dispensing, management, patient care, practice development, and other activities; 3) the number of pharmacist patient care services provided per pharmacist hours worked; and 4) percentage of time that technician product verification was used. There was no significant difference in overall errors (0.2729% vs. 0.5124%, P = 0.513), patient safety errors (0.0525% vs. 0.0651%, P = 0.837), or administrative errors (0.2204% vs. 0.4784%, P = 0.411). Pharmacist's time in dispensing significantly decreased (67.3% vs. 49.06%, P = 0.005), and time in direct patient care (19.96% vs. 34.72%, P = 0.003), increased significantly. Time in other activities did not significantly change. Reimbursable services per pharmacist hour (0.11 vs. 0.30, P = 0.129), did not significantly change. Non-reimbursable services increased significantly (2.77 vs. 4.80, P = 0.042). Total services significantly increased (2.88 vs. 5.16, P = 0.044). Pharmacy technician product verification of refill prescriptions preserved dispensing safety while significantly increasing the time spent in delivery of pharmacist provided patient care services. The total number of pharmacist services provided per hour also increased significantly, driven primarily by a significant increase in the number of non-reimbursed services. This was mostly likely due to the increased time available to provide patient care. Reimbursed services per hour did not increase significantly mostly likely due to lack of payers. Copyright © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Patient Safety in the Context of Neonatal Intensive Care: Research and Educational Opportunities

PubMed Central

Raju, Tonse N. K.; Suresh, Gautham; Higgins, Rosemary D.

2012-01-01

Case reports and observational studies continue to report adverse events from medical errors. However, despite considerable attention to patient safety in the popular media, this topic is not a regular component of medical education, and much research needs to be carried out to understand the causes, consequences, and prevention of healthcare-related adverse events during neonatal intensive care. To address the knowledge gaps and to formulate a research and educational agenda in neonatology, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) invited a panel of experts to a workshop in August 2010. Patient safety issues discussed were: the reasons for errors, including systems design, working conditions, and worker fatigue; a need to develop a “culture” of patient safety; the role of electronic medical records, information technology, and simulators in reducing errors; error disclosure practices; medico-legal concerns; and educational needs. Specific neonatology-related topics discussed were: errors during resuscitation, mechanical ventilation, and performance of invasive procedures; medication errors including those associated with milk feedings; diagnostic errors; and misidentification of patients. This article provides an executive summary of the workshop. PMID:21386749

Accurate Sample Assignment in a Multiplexed, Ultrasensitive, High-Throughput Sequencing Assay for Minimal Residual Disease.

PubMed

Bartram, Jack; Mountjoy, Edward; Brooks, Tony; Hancock, Jeremy; Williamson, Helen; Wright, Gary; Moppett, John; Goulden, Nick; Hubank, Mike

2016-07-01

High-throughput sequencing (HTS) (next-generation sequencing) of the rearranged Ig and T-cell receptor genes promises to be less expensive and more sensitive than current methods of monitoring minimal residual disease (MRD) in patients with acute lymphoblastic leukemia. However, the adoption of new approaches by clinical laboratories requires careful evaluation of all potential sources of error and the development of strategies to ensure the highest accuracy. Timely and efficient clinical use of HTS platforms will depend on combining multiple samples (multiplexing) in each sequencing run. Here we examine the Ig heavy-chain gene HTS on the Illumina MiSeq platform for MRD. We identify errors associated with multiplexing that could potentially impact the accuracy of MRD analysis. We optimize a strategy that combines high-purity, sequence-optimized oligonucleotides, dual indexing, and an error-aware demultiplexing approach to minimize errors and maximize sensitivity. We present a probability-based, demultiplexing pipeline Error-Aware Demultiplexer that is suitable for all MiSeq strategies and accurately assigns samples to the correct identifier without excessive loss of data. Finally, using controls quantified by digital PCR, we show that HTS-MRD can accurately detect as few as 1 in 10(6) copies of specific leukemic MRD. Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.

Radiometric analysis of the longwave infrared channel of the Thematic Mapper on LANDSAT 4 and 5

NASA Technical Reports Server (NTRS)

Schott, John R.; Volchok, William J.; Biegel, Joseph D.

1986-01-01

The first objective was to evaluate the postlaunch radiometric calibration of the LANDSAT Thematic Mapper (TM) band 6 data. The second objective was to determine to what extent surface temperatures could be computed from the TM and 6 data using atmospheric propagation models. To accomplish this, ground truth data were compared to a single TM-4 band 6 data set. This comparison indicated satisfactory agreement over a narrow temperature range. The atmospheric propagation model (modified LOWTRAN 5A) was used to predict surface temperature values based on the radiance at the spacecraft. The aircraft data were calibrated using a multi-altitude profile calibration technique which had been extensively tested in previous studies. This aircraft calibration permitted measurement of surface temperatures based on the radiance reaching the aircraft. When these temperature values are evaluated, an error in the satellite's ability to predict surface temperatures can be estimated. This study indicated that by carefully accounting for various sensor calibration and atmospheric propagation effects, and expected error (1 standard deviation) in surface temperature would be 0.9 K. This assumes no error in surface emissivity and no sampling error due to target location. These results indicate that the satellite calibration is within nominal limits to within this study's ability to measure error.

The Environmental Context of Patient Safety and Medical Errors

ERIC Educational Resources Information Center

Wholey, Douglas; Moscovice, Ira; Hietpas, Terry; Holtzman, Jeremy

2004-01-01

The environmental context of patient safety and medical errors was explored with specific interest in rural settings. Special attention was paid to unique features of rural health care organizations and their environment that relate to the patient safety issue and medical errors (including the distribution of patients, types of adverse events…

Laboratory medicine handoff gaps experienced by primary care practices: A report from the shared networks of collaborative ambulatory practices and partners (SNOCAP).

PubMed

West, David R; James, Katherine A; Fernald, Douglas H; Zelie, Claire; Smith, Maxwell L; Raab, Stephen S

2014-01-01

The majority of errors in laboratory medicine testing are thought to occur in the pre- and postanalytic testing phases, and a large proportion of these errors are secondary to failed handoffs. Because most laboratory tests originate in ambulatory primary care, understanding the gaps in handoff processes within and between laboratories and practices is imperative for patient safety. Therefore, the purpose of this study was to understand, based on information from primary care practice personnel, the perceived gaps in laboratory processes as a precursor to initiating process improvement activities. A survey was used to assess perceptions of clinicians, staff, and management personnel of gaps in handoffs between primary care practices and laboratories working in 21 Colorado primary care practices. Data were analyzed to determine statistically significant associations between categorical variables. In addition, qualitative analysis of responses to open-ended survey questions was conducted. Primary care practices consistently reported challenges and a desire/need to improve their efforts to systematically track laboratory test status, confirm receipt of laboratory results, and report results to patients. Automated tracking systems existed in roughly 61% of practices, and all but one of those had electronic health record-based tracking systems in place. One fourth of these electronic health record-enabled practices expressed sufficient mistrust in these systems to warrant the concurrent operation of an article-based tracking system as backup. Practices also reported 12 different procedures used to notify patients of test results, varying by test result type. The results highlight the lack of standardization and definition of roles in handoffs in primary care laboratory practices for test ordering, monitoring, and receiving and reporting test results. Results also identify high-priority gaps in processes and the perceptions by practice personnel that practice improvement in these areas is needed. Commonalities in these areas warrant the development and support of tools for use in primary care settings. © Copyright 2014 by the American Board of Family Medicine.

The Relationship Between Work Commitment, Dynamic, and Medication Error.

PubMed

Rezaiamin, Abdoolkarim; Pazokian, Marzieh; Zagheri Tafreshi, Mansoureh; Nasiri, Malihe

2017-05-01

Incidence of medication errors in intensive care unit (ICU) can cause irreparable damage for ICU patients. Therefore, it seems necessary to find the causes of medication errors in this section. Work commitment and dynamic might affect the incidence of medication errors in ICU. To assess the mentioned hypothesis, we performed a descriptive-analytical study which was carried out on 117 nurses working in ICU of educational hospitals in Tehran. Minick et al., Salyer et al., and Wakefield et al. scales were used for data gathering on work commitment, dynamic, and medication errors, respectively. Findings of the current study revealed that high work commitment in ICU nurses caused low number of medication errors, including intravenous and nonintravenous. We controlled the effects of confounding variables in detection of this relationship. In contrast, no significant association was found between work dynamic and different types of medication errors. Although the study did not observe any relationship between the dynamics and rate of medication errors, the training of nurses or nursing students to create a dynamic environment in hospitals can increase their interest in the profession and increase job satisfaction in them. Also they must have enough ability in work dynamic so that they don't confused and distracted result in frequent changes of orders, care plans, and procedures.

Pulse contour analysis of arterial waveform in a high fidelity human patient simulator.

PubMed

Persona, Paolo; Saraceni, Elisabetta; Facchin, Francesca; Petranzan, Enrico; Parotto, Matteo; Baratto, Fabio; Ori, Carlo; Rossi, Sandra

2017-10-03

The measurement of cardiac output (CO) may be useful to improve the assessment of hemodynamics during simulated scenarios. The purpose of this study was to evaluate the feasibility of introducing an uncalibrated pulse contour device (MostCare, Vytech, Vygon, Padova, Italy) into the simulation environment. MostCare device was plugged to a clinical monitor and connected to the METI human patient simulator (HPS) to obtain a continuous arterial waveform analysis and CO calculation. In six different simulated clinical scenarios (baseline, ventricular failure, vasoplegic shock, hypertensive crisis, hypovolemic shock and aortic stenosis), the HPS-CO and the MostCare-CO were simultaneously recorded. The level of concordance between the two methods was assessed by the Bland and Altman analysis. 150-paired CO values were obtained. The HPS-CO values ranged from 2.3 to 6.6 L min -1 and the MostCare-CO values from 2.8 to 6.4 L min -1 . The mean difference between HPS-CO and MostCare-CO was - 0.3 L min -1 and the limits of agreement were - 1.5 and 0.9 L min -1 . The percentage of error was 23%. A good correlation between HPS-CO and MostCare-CO was observed in each scenario of the study (r = 0.88). Although MostCare-CO tended to underestimate the CO over the study period, good agreements were found between the two methods. Therefore, a pulse contour device can be integrated into the simulation environment, offering the opportunity to create new simulated clinical settings.

Descriptive analysis of medication errors reported to the Egyptian national online reporting system during six months.

PubMed

Shehata, Zahraa Hassan Abdelrahman; Sabri, Nagwa Ali; Elmelegy, Ahmed Abdelsalam

2016-03-01

This study analyzes reports to the Egyptian medication error (ME) reporting system from June to December 2014. Fifty hospital pharmacists received training on ME reporting using the national reporting system. All received reports were reviewed and analyzed. The pieces of data analyzed were patient age, gender, clinical setting, stage, type, medication(s), outcome, cause(s), and recommendation(s). Over the course of 6 months, 12,000 valid reports were gathered and included in this analysis. The majority (66%) came from inpatient settings, while 23% came from intensive care units, and 11% came from outpatient departments. Prescribing errors were the most common type of MEs (54%), followed by monitoring (25%) and administration errors (16%). The most frequent error was incorrect dose (20%) followed by drug interactions, incorrect drug, and incorrect frequency. Most reports were potential (25%), prevented (11%), or harmless (51%) errors; only 13% of reported errors lead to patient harm. The top three medication classes involved in reported MEs were antibiotics, drugs acting on the central nervous system, and drugs acting on the cardiovascular system. Causes of MEs were mostly lack of knowledge, environmental factors, lack of drug information sources, and incomplete prescribing. Recommendations for addressing MEs were mainly staff training, local ME reporting, and improving work environment. There are common problems among different healthcare systems, so that sharing experiences on the national level is essential to enable learning from MEs. Internationally, there is a great need for standardizing ME terminology, to facilitate knowledge transfer. Underreporting, inaccurate reporting, and a lack of reporter diversity are some limitations of this study. Egypt now has a national database of MEs that allows researchers and decision makers to assess the problem, identify its root causes, and develop preventive strategies. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Meaningful Peer Review in Radiology: A Review of Current Practices and Potential Future Directions.

PubMed

Moriarity, Andrew K; Hawkins, C Matthew; Geis, J Raymond; Dreyer, Keith J; Kamer, Aaron P; Khandheria, Paras; Morey, Jose; Whitfill, James; Wiggins, Richard H; Itri, Jason N

2016-12-01

The current practice of peer review within radiology is well developed and widely implemented compared with other medical specialties. However, there are many factors that limit current peer review practices from reducing diagnostic errors and improving patient care. The development of "meaningful peer review" requires a transition away from compliance toward quality improvement, whereby the information and insights gained facilitate education and drive systematic improvements that reduce the frequency and impact of diagnostic error. The next generation of peer review requires significant improvements in IT functionality and integration, enabling features such as anonymization, adjudication by multiple specialists, categorization and analysis of errors, tracking, feedback, and easy export into teaching files and other media that require strong partnerships with vendors. In this article, the authors assess various peer review practices, with focused discussion on current limitations and future needs for meaningful peer review in radiology. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Fuzzy modelling and efficiency in health care systems.

PubMed

Ozok, Ahmet F

2012-01-01

American Medical Institute reports that each year, because of the medical error, minimum fifty thousand people are dead. For a safety and quality medical system, it is important that information systems are used in health care systems. Health information applications help us to reduce the human error and to support patient care systems. Recently, it is reported that medical information systems applications have also some negative effect on all medical integral elements. The cost of health care information systems is about 4.6% of the total cost. In this paper, it is tried a risk determination model according to principles of fuzzy logic. The improvement of health care systems has become a very popular topic in Turkey recent years. Using necessary information system; it became possible to care patients in a safer way. However, using the necessary HIS tools to manage of administrative and clinical processes at hospitals became more important than before. For example; clinical work flows and communication among pharmacists, nurses and physicians are still not enough investigated. We use fuzzy modeling as a research strategy and developed sum fuzzy membership functions to minimize human error. In application in Turkey the results are significantly related with each other. Besides, the sign differences in health care information systems strongly effects of risk magnitude. The obtained results are discussed and some comments are added.

“Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention”

PubMed Central

2013-01-01

Background We describe and evaluate the development and use of a Clinical Decision Support (CDS) intervention; an alert, in response to an identified medical error of overuse of a diagnostic laboratory test in a Computerized Physician Order Entry (CPOE) system. CPOE with embedded CDS has been shown to improve quality of care and reduce medical errors. CPOE can also improve resource utilization through more appropriate use of laboratory tests and diagnostic studies. Observational studies are necessary in order to understand how these technologies can be successfully employed by healthcare providers. Methods The error was identified by the Test Utilization Committee (TUC) in September, 2008 when they noticed critical care patients were being tested daily, and sometimes twice daily, for B-Type Natriuretic Peptide (BNP). Repeat and/or serial BNP testing is inappropriate for guiding the management of heart failure and may be clinically misleading. The CDS intervention consists of an expert rule that searches the system for a BNP lab value on the patient. If there is a value and the value is within the current hospital stay, an advisory is displayed to the ordering clinician. In order to isolate the impact of this intervention on unnecessary BNP testing we applied multiple regression analysis to the sample of 41,306 patient admissions with at least one BNP test at LVHN between January, 2008 and September, 2011. Results Our regression results suggest the CDS intervention reduced BNP orders by 21% relative to the mean. The financial impact of the rule was also significant. Multiplying by the direct supply cost of $28.04 per test, the intervention saved approximately $92,000 per year. Conclusions The use of alerts has great positive potential to improve care, but should be used judiciously and in the appropriate environment. While these savings may not be generalizable to other interventions, the experience at LVHN suggests that appropriately designed and carefully implemented CDS interventions can have a substantial impact on the efficiency of care provision. PMID:23566021

Medicaid/CHIP Program; Medicaid Program and Children's Health Insurance Program (CHIP); Changes to the Medicaid Eligibility Quality Control and Payment Error Rate Measurement Programs in Response to the Affordable Care Act. Final rule.

PubMed

2017-07-05

This final rule updates the Medicaid Eligibility Quality Control (MEQC) and Payment Error Rate Measurement (PERM) programs based on the changes to Medicaid and the Children's Health Insurance Program (CHIP) eligibility under the Patient Protection and Affordable Care Act. This rule also implements various other improvements to the PERM program.

Contemporary issues: The pre-licensure nursing student and medication errors.

PubMed

Green, Cheryl

2018-06-01

In Modern health care, the creation of cultures of safety for patients is of the upmost importance. Impacting the institutional stabilization of health care facilities safety initiatives, is the preparation of pre-licensure nursing students to safely administer medications to patients. Therefore, preparation of the pre-licensure nursing student must be evidence-based practice focused and incorporate innovative ways to reduce the potential for medication errors. Copyright © 2018. Published by Elsevier Ltd.

Error detection and reduction in blood banking.

PubMed

Motschman, T L; Moore, S B

1996-12-01

Error management plays a major role in facility process improvement efforts. By detecting and reducing errors, quality and, therefore, patient care improve. It begins with a strong organizational foundation of management attitude with clear, consistent employee direction and appropriate physical facilities. Clearly defined critical processes, critical activities, and SOPs act as the framework for operations as well as active quality monitoring. To assure that personnel can detect an report errors they must be trained in both operational duties and error management practices. Use of simulated/intentional errors and incorporation of error detection into competency assessment keeps employees practiced, confident, and diminishes fear of the unknown. Personnel can clearly see that errors are indeed used as opportunities for process improvement and not for punishment. The facility must have a clearly defined and consistently used definition for reportable errors. Reportable errors should include those errors with potentially harmful outcomes as well as those errors that are "upstream," and thus further away from the outcome. A well-written error report consists of who, what, when, where, why/how, and follow-up to the error. Before correction can occur, an investigation to determine the underlying cause of the error should be undertaken. Obviously, the best corrective action is prevention. Correction can occur at five different levels; however, only three of these levels are directed at prevention. Prevention requires a method to collect and analyze data concerning errors. In the authors' facility a functional error classification method and a quality system-based classification have been useful. An active method to search for problems uncovers them further upstream, before they can have disastrous outcomes. In the continual quest for improving processes, an error management program is itself a process that needs improvement, and we must strive to always close the circle of quality assurance. Ultimately, the goal of better patient care will be the reward.

HealthCare.gov

MedlinePlus

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Factors effective on medication errors: A nursing view.

PubMed

Shahrokhi, Akram; Ebrahimpour, Fatemeh; Ghodousi, Arash

2013-01-01

Medication errors are the most common medical errors, which may result in some complications for patients. This study was carried out to investigate what influence medication errors by nurses from their viewpoint. In this descriptive study, 150 nurses who were working in Qazvin Medical University teaching hospitals were selected by proportional random sampling, and data were collected by means of a researcher-made questionnaire including demographic attributes (age, gender, working experience,…), and contributing factors in medication errors (in three categories including nurse-related, management-related, and environment-related factors). The mean age of the participant nurses was 30.7 ± 6.5 years. Most of them (87.1%) were female with a Bachelor of Sciences degree (86.7%) in nursing. The mean of their overtime working was 64.8 ± 38 h/month. The results showed that the nurse-related factors are the most effective factors (55.44 ± 9.14) while the factors related to the management system (52.84 ± 11.24) and the ward environment (44.0 ± 10.89) are respectively less effective. The difference between these three groups was significant (P = 0.000). In each aforementioned category, the most effective factor on medication error (ranked from the most effective to the least effective) were as follow: The nurse's inadequate attention (98.7%), the errors occurring in the transfer of medication orders from the patient's file to kardex (96.6%) and the ward's heavy workload (86.7%). In this study nurse-related factors were the most effective factors on medication errors, but nurses are one of the members of health-care providing team, so their performance must be considered in the context of the health-care system like work force condition, rules and regulations, drug manufacturing that might impact nurses performance, so it could not be possible to prevent medication errors without paying attention to our health-care system in a holistic approach.

Factors effective on medication errors: A nursing view

PubMed Central

Shahrokhi, Akram; Ebrahimpour, Fatemeh; Ghodousi, Arash

2013-01-01

Objective: Medication errors are the most common medical errors, which may result in some complications for patients. This study was carried out to investigate what influence medication errors by nurses from their viewpoint. Methods: In this descriptive study, 150 nurses who were working in Qazvin Medical University teaching hospitals were selected by proportional random sampling, and data were collected by means of a researcher-made questionnaire including demographic attributes (age, gender, working experience,…), and contributing factors in medication errors (in three categories including nurse-related, management-related, and environment-related factors). Findings: The mean age of the participant nurses was 30.7 ± 6.5 years. Most of them (87.1%) were female with a Bachelor of Sciences degree (86.7%) in nursing. The mean of their overtime working was 64.8 ± 38 h/month. The results showed that the nurse-related factors are the most effective factors (55.44 ± 9.14) while the factors related to the management system (52.84 ± 11.24) and the ward environment (44.0 ± 10.89) are respectively less effective. The difference between these three groups was significant (P = 0.000). In each aforementioned category, the most effective factor on medication error (ranked from the most effective to the least effective) were as follow: The nurse's inadequate attention (98.7%), the errors occurring in the transfer of medication orders from the patient's file to kardex (96.6%) and the ward's heavy workload (86.7%). Conclusion: In this study nurse-related factors were the most effective factors on medication errors, but nurses are one of the members of health-care providing team, so their performance must be considered in the context of the health-care system like work force condition, rules and regulations, drug manufacturing that might impact nurses performance, so it could not be possible to prevent medication errors without paying attention to our health-care system in a holistic approach. PMID:24991599

Small-Volume Injections: Evaluation of Volume Administration Deviation From Intended Injection Volumes.

PubMed

Muffly, Matthew K; Chen, Michael I; Claure, Rebecca E; Drover, David R; Efron, Bradley; Fitch, William L; Hammer, Gregory B

2017-10-01

In the perioperative period, anesthesiologists and postanesthesia care unit (PACU) nurses routinely prepare and administer small-volume IV injections, yet the accuracy of delivered medication volumes in this setting has not been described. In this ex vivo study, we sought to characterize the degree to which small-volume injections (≤0.5 mL) deviated from the intended injection volumes among a group of pediatric anesthesiologists and pediatric postanesthesia care unit (PACU) nurses. We hypothesized that as the intended injection volumes decreased, the deviation from those intended injection volumes would increase. Ten attending pediatric anesthesiologists and 10 pediatric PACU nurses each performed a series of 10 injections into a simulated patient IV setup. Practitioners used separate 1-mL tuberculin syringes with removable 18-gauge needles (Becton-Dickinson & Company, Franklin Lakes, NJ) to aspirate 5 different volumes (0.025, 0.05, 0.1, 0.25, and 0.5 mL) of 0.25 mM Lucifer Yellow (LY) fluorescent dye constituted in saline (Sigma Aldrich, St. Louis, MO) from a rubber-stoppered vial. Each participant then injected the specified volume of LY fluorescent dye via a 3-way stopcock into IV tubing with free-flowing 0.9% sodium chloride (10 mL/min). The injected volume of LY fluorescent dye and 0.9% sodium chloride then drained into a collection vial for laboratory analysis. Microplate fluorescence wavelength detection (Infinite M1000; Tecan, Mannedorf, Switzerland) was used to measure the fluorescence of the collected fluid. Administered injection volumes were calculated based on the fluorescence of the collected fluid using a calibration curve of known LY volumes and associated fluorescence.To determine whether deviation of the administered volumes from the intended injection volumes increased at lower injection volumes, we compared the proportional injection volume error (loge [administered volume/intended volume]) for each of the 5 injection volumes using a linear regression model. Analysis of variance was used to determine whether the absolute log proportional error differed by the intended injection volume. Interindividual and intraindividual deviation from the intended injection volume was also characterized. As the intended injection volumes decreased, the absolute log proportional injection volume error increased (analysis of variance, P < .0018). The exploratory analysis revealed no significant difference in the standard deviations of the log proportional errors for injection volumes between physicians and pediatric PACU nurses; however, the difference in absolute bias was significantly higher for nurses with a 2-sided significance of P = .03. Clinically significant dose variation occurs when injecting volumes ≤0.5 mL. Administering small volumes of medications may result in unintended medication administration errors.

[Pharmaceutical care strategies to prevent medication errors].

PubMed

Ucha-Samartín, Marisol; Martínez-López de Castro, Noemí; Troncoso-Mariño, Amelia; Campelo-Sánchez, Eva; Vázquez-López, Cristina; Inaraja-Bobo, María Teresa

2009-08-01

To evaluate the impact of implementing new programs to improve the quality of the pharmaceutical care and unit-dose distribution system for in-patients. An observational and prospective study was carried out in a general hospital during two different six-monthly period. Transcription and dispensation errors were evaluated in twelve wards during the first six months. Then, two new measures were introduced: the first- reference ward-pharmacist and the second-a new protocol for checking medication on the ward. Results were evaluated by SPSS v. 14 program. In the transcription evaluation, units without a ward pharmacist did not improve. Transcription errors significantly decreased in three units: gynaecology-urology (3.24% vs. 0.52%), orthopaedic (2% vs. 1.69%) and neurology-pneumology (2.81% vs. 2.02%). In dispensing, only units with the new protocol decreased their medication errors (1.77% vs. 1.24%). The participation of pharmacists in multidisciplinary teams and exhaustive protocols for dispensing medication were effective in detecting and decreasing medication errors in patients.

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

PubMed

Steinberger, Dina M; Douglas, Stephen V; Kirschbaum, Mark S

2009-09-01

A multidisciplinary team from the University of Wisconsin Hospital and Clinics transplant program used failure mode and effects analysis to proactively examine opportunities for communication and handoff failures across the continuum of care from organ procurement to transplantation. The team performed a modified failure mode and effects analysis that isolated the multiple linked, serial, and complex information exchanges occurring during the transplantation of one solid organ. Failure mode and effects analysis proved effective for engaging a diverse group of persons who had an investment in the outcome in analysis and discussion of opportunities to improve the system's resilience for avoiding errors during a time-pressured and complex process.

Interventions to reduce medication errors in neonatal care: a systematic review

PubMed Central

Nguyen, Minh-Nha Rhylie; Mosel, Cassandra

2017-01-01

Background: Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors. Methods: A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and reference-list checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting. Results: A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50–70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors. Conclusion: While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice. PMID:29387337

The role of the emergency medical dispatch centre (EMDC) and prehospital emergency care safety: results from an incident report (IR) system.

PubMed

Mortaro, Alberto; Pascu, Diana; Zerman, Tamara; Vallaperta, Enrico; Schönsberg, Alberto; Tardivo, Stefano; Pancheri, Serena; Romano, Gabriele; Moretti, Francesca

2015-07-01

The role of the emergency medical dispatch centre (EMDC) is essential to ensure coordinated and safe prehospital care. The aim of this study was to implement an incident report (IR) system in prehospital emergency care management with a view to detecting errors occurring in this setting and guiding the implementation of safety improvement initiatives. An ad hoc IR form for the prehospital setting was developed and implemented within the EMDC of Verona. The form included six phases (from the emergency call to hospital admission) with the relevant list of potential error modes (30 items). This descriptive observational study considered the results from 268 consecutive days between February and November 2010. During the study period, 161 error modes were detected. The majority of these errors occurred in the resource allocation and timing phase (34.2%) and in the dispatch phase (31.0%). Most of the errors were due to human factors (77.6%), and almost half of them were classified as either moderate (27.9%) or severe (19.9%). These results guided the implementation of specific corrective actions, such as the adoption of a more efficient Medical Priority Dispatch System and the development of educational initiatives targeted at both EMDC staff and the population. Despite the intrinsic limits of IR methodology, results suggest how the implementation of an IR system dedicated to the emergency prehospital setting can act as a major driver for the development of a "learning organization" and improve both efficacy and safety of first aid care.

System care improves trauma outcome: patient care errors dominate reduced preventable death rate.

PubMed

Thoburn, E; Norris, P; Flores, R; Goode, S; Rodriguez, E; Adams, V; Campbell, S; Albrink, M; Rosemurgy, A

1993-01-01

A review of 452 trauma deaths in Hillsborough County, Florida, in 1984 documented that 23% of non-CNS trauma deaths were preventable and occurred because of inadequate resuscitation or delay in proper surgical care. In late 1988 Hillsborough County organized a County Trauma Agency (HCTA) to coordinate trauma care among prehospital providers and state-designated trauma centers. The purpose of this study was to review county trauma deaths after the inception of the HCTA to determine the frequency of preventable deaths. 504 trauma deaths occurring between October 1989 and April 1991 were reviewed. Through committee review, 10 deaths were deemed preventable; 2 occurred outside the trauma system. Of the 10 deaths, 5 preventable deaths occurred late in severely injured patients. The preventable death rate has decreased to 7.0% with system care. The causes of preventable deaths have changed from delayed or inadequate intervention to postoperative care errors.

Corruption, inequality and population perception of healthcare quality in Europe

PubMed Central

2013-01-01

Background Evaluating the quality of healthcare and patient safety using general population questionnaires is important from research and policy perspective. Using a special wave of the Eurobarometer survey, we analysed the general population’s perception of health care quality and patient safety in a cross-country setting. Methods We used ordered probit, ordinary least squares and probit analysis to estimate the determinants of health care quality, and ordered logit analysis to analyse the likelihood of being harmed by a specific medical procedure. The models used population weights as well as country-clustered standard errors. Results We found robust evidence for the impact of socio-demographic variables on the perception of quality of health care. More specifically, we found a non-linear impact of age on the perception of quality of health care and patient safety, as well as a negative impact of poverty on both perception of quality and patient safety. We also found robust evidence that countries with higher corruption levels were associated with worse perceptions of quality of health care. Finally, we found evidence that income inequality affects patients’ perception vis-à-vis safety, thus feeding into the poverty/health care quality nexus. Conclusions Socio-demographic factors and two macro variables (corruption and income inequality) explain the perception of quality of health care and likelihood of being harmed by adverse events. The results carry significant policy weight and could explain why targeting only the health care sector (without an overall reform of the public sector) could potentially be challenging. PMID:24215401

Corruption, inequality and population perception of healthcare quality in Europe.

PubMed

Nikoloski, Zlatko; Mossialos, Elias

2013-11-11

Evaluating the quality of healthcare and patient safety using general population questionnaires is important from research and policy perspective. Using a special wave of the Eurobarometer survey, we analysed the general population's perception of health care quality and patient safety in a cross-country setting. We used ordered probit, ordinary least squares and probit analysis to estimate the determinants of health care quality, and ordered logit analysis to analyse the likelihood of being harmed by a specific medical procedure. The models used population weights as well as country-clustered standard errors. We found robust evidence for the impact of socio-demographic variables on the perception of quality of health care. More specifically, we found a non-linear impact of age on the perception of quality of health care and patient safety, as well as a negative impact of poverty on both perception of quality and patient safety. We also found robust evidence that countries with higher corruption levels were associated with worse perceptions of quality of health care. Finally, we found evidence that income inequality affects patients' perception vis-à-vis safety, thus feeding into the poverty/health care quality nexus. Socio-demographic factors and two macro variables (corruption and income inequality) explain the perception of quality of health care and likelihood of being harmed by adverse events. The results carry significant policy weight and could explain why targeting only the health care sector (without an overall reform of the public sector) could potentially be challenging.

Iranian family caregivers’ challenges and issues in caring of multiple sclerosis patients: A descriptive explorative qualitative study

PubMed Central

Masoudi, Reza; Abedi, Heidar Ali; Abedi, Parvin; Mohammadianinejad, Seyed Ehsan

2014-01-01

Background: The broad spectrum of problems caused by multiple sclerosis (MS) imposes heavy responsibility to caregivers in caring of their patients. Therefore, they encounter many issues and challenges in this situation. The purpose of this study was to explore the experiences and challenges of MS family caregivers. Materials and Methods: A qualitative design, based on a thematic analysis approach, was used to reach the study aim. Data were collected and analyzed concurrently through in-depth unstructured interviews, field notes, and observations that were held with 23 participants (14 family caregivers and 9 MS patients) at two referral centers in Ahvaz, Iran. Findings: Three major themes were extracted from the analysis of the transcripts: “emotional exhaustion of caregivers,” “uncertain atmosphere of caring,” and “insularity care.” The first theme consisted of three subthemes: “stressful atmosphere of caring,” “conflict and animism,” and “continuing distress affecting the caregiver.” The second theme consisted of three subthemes: “unstable and complicacy of disease,” “caring with trial and error,” and “frequent hospitalization of patients,” and the third theme consisted of two subthemes: “caring gap and disintegration” and “lack of sufficient support.” Conclusions: This study will be useful to healthcare system for managing the challenges of MS patients’ family caregivers. Improving the conditions and performance of family caregivers is crucial in order to provide high-quality care to people with MS. PMID:25183985

[A new method of processing quantitative PCR data].

PubMed

Ke, Bing-Shen; Li, Guang-Yun; Chen, Shi-Min; Huang, Xiang-Yan; Chen, Ying-Jian; Xu, Jun

2003-05-01

Today standard PCR can't satisfy the need of biotechnique development and clinical research any more. After numerous dynamic research, PE company found there is a linear relation between initial template number and cycling time when the accumulating fluorescent product is detectable.Therefore,they developed a quantitative PCR technique to be used in PE7700 and PE5700. But the error of this technique is too great to satisfy the need of biotechnique development and clinical research. A better quantitative PCR technique is needed. The mathematical model submitted here is combined with the achievement of relative science,and based on the PCR principle and careful analysis of molecular relationship of main members in PCR reaction system. This model describes the function relation between product quantity or fluorescence intensity and initial template number and other reaction conditions, and can reflect the accumulating rule of PCR product molecule accurately. Accurate quantitative PCR analysis can be made use this function relation. Accumulated PCR product quantity can be obtained from initial template number. Using this model to do quantitative PCR analysis,result error is only related to the accuracy of fluorescence intensity or the instrument used. For an example, when the fluorescence intensity is accurate to 6 digits and the template size is between 100 to 1,000,000, the quantitative result accuracy will be more than 99%. The difference of result error is distinct using same condition,same instrument but different analysis method. Moreover,if the PCR quantitative analysis system is used to process data, it will get result 80 times of accuracy than using CT method.

Theoretical considerations to optimize transabdominal monitoring of fetal arterial blood oxygenation using pulse oximetry

NASA Astrophysics Data System (ADS)

Zourabian, Anna; Boas, David A.

2001-06-01

Pulse oximetry (oxygen saturation monitoring) has markedly improved medical care in many fields, including anesthesiology, intensive care, and newborn intensive care. In obstetrics, fetal heart rate monitoring remains the standard for intrapartum assessment of fetal well being. Fetal oxygen saturation monitoring is a new technique currently under development. It is potentially superior to electronic fetal heart rate monitoring (cardiotocography) because it allows direct assessment of both fetal oxygen status and fetal tissue perfusion. Here we present the analysis for determining the most optimal wavelength selection for pulse oximetry. The wavelengths we chose as the most optimal are: the first in the range of 670-720nm and the second in the range of 825-925nm. Further we discuss the possible systematic errors during our measurements, and their contribution to the obtained saturation results.

Pediatric aspects of inpatient health information technology systems.

PubMed

Lehmann, Christoph U

2015-03-01

In the past 3 years, the Health Information Technology for Economic and Clinical Health Act accelerated the adoption of electronic health records (EHRs) with providers and hospitals, who can claim incentive monies related to meaningful use. Despite the increase in adoption of commercial EHRs in pediatric settings, there has been little support for EHR tools and functionalities that promote pediatric quality improvement and patient safety, and children remain at higher risk than adults for medical errors in inpatient environments. Health information technology (HIT) tailored to the needs of pediatric health care providers can improve care by reducing the likelihood of errors through information assurance and minimizing the harm that results from errors. This technical report outlines pediatric-specific concepts, child health needs and their data elements, and required functionalities in inpatient clinical information systems that may be missing in adult-oriented HIT systems with negative consequences for pediatric inpatient care. It is imperative that inpatient (and outpatient) HIT systems be adapted to improve their ability to properly support safe health care delivery for children. Copyright © 2015 by the American Academy of Pediatrics.

Application of the SEIPS Model to Analyze Medication Safety in a Crisis Residential Center.

PubMed

Steele, Maria L; Talley, Brenda; Frith, Karen H

2018-02-01

Medication safety and error reduction has been studied in acute and long-term care settings, but little research is found in the literature regarding mental health settings. Because mental health settings are complex, medication administration is vulnerable to a variety of errors from transcription to administration. The purpose of this study was to analyze critical factors related to a mental health work system structure and processes that threaten safe medication administration practices. The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework to analyze factors affecting medication safety. The model approach analyzes the work system concepts of technology, tasks, persons, environment, and organization to guide the collection of data. In the study, the Lean methodology tools were used to identify vulnerabilities in the system that could be targeted later for improvement activities. The project director completed face-to-face interviews, asked nurses to record disruptions in a log, and administered a questionnaire to nursing staff. The project director also conducted medication chart reviews and recorded medication errors using a standardized taxonomy for errors that allowed categorization of the prevalent types of medication errors. Results of the study revealed disruptions during the medication process, pharmacology training needs, and documentation processes as the primary opportunities for improvement. The project engaged nurses to identify sustainable quality improvement strategies to improve patient safety. The mental health setting carries challenges for safe medication administration practices. Through analysis of the structure, process, and outcomes of medication administration, opportunities for quality improvement and sustainable interventions were identified, including minimizing the number of distractions during medication administration, training nurses on psychotropic medications, and improving the documentation system. A task force was created to analyze the descriptive data and to establish objectives aimed at improving efficiency of the work system and care process involved in medication administration at the end of the project. Copyright © 2017 Elsevier Inc. All rights reserved.

Inaccurate Language Interpretation and its Clinical Significance in the Medical Encounters of Spanish-speaking Latinos

PubMed Central

Nápoles, Anna M.; Santoyo-Olsson, Jasmine; Karliner, Leah S.; Gregorich, Steven E.; Pérez-Stable, Eliseo J.

2015-01-01

Background Limited English-proficient (LEP) patients suffer poorer quality of care and outcomes. Interpreters can ameliorate these disparities; however, evidence is lacking on the quality of different interpretation modes. Objective Compare accuracy of interpretation for in-person professional (IP), professional videoconferencing (VC), and ad hoc interpretation (AH). Design Cross-sectional study of transcribed audiotaped primary care visits Subjects 32 Spanish-speaking Latino patients; 14 clinicians Measures Independent coding of transcripts by four coders (two were internists) for accurate and inaccurate interpretation instances. Unit of analysis was a segment of continuous speech or text unit (TU). Two internists independently verified inaccurate interpretation instances and rated their clinical significance as clinically insignificant, mildly, moderately or highly clinically significant. Results Accurate interpretation made up 70% of total coded TUs and inaccurate interpretation (errors) made up 30%. Inaccurate interpretation occurred at twice the rate for AH (54% of coded TUs) versus IP (25%) and VC (23%) interpretation, due to more errors of omission (p<0.001) and answers for patient or clinician (p<0.001). Mean number of errors per visit was 27, with 7.1% of errors rated as moderately/highly clinically significant. In adjusted models, the odds of inaccurate interpretation were lower for IP (OR = −1.25, 95% CI −1.56, −0.95) and VC (OR = −1.05; 95% CI −1.26, −0.84) than for AH interpreted visits; the odds of a moderately/highly clinically significant error were lower for IP (OR = −0.06; 95% CI −1.05, 0.92) than for AH interpreted visits. Conclusions Inaccurate language interpretation in medical encounters is common and more frequent when untrained interpreters are used compared to professional in-person or via videoconferencing. Professional video conferencing interpretation may increase access to higher quality medical interpretation services. PMID:26465121

The Impact of Bar Code Medication Administration Technology on Reported Medication Errors

ERIC Educational Resources Information Center

Holecek, Andrea

2011-01-01

The use of bar-code medication administration technology is on the rise in acute care facilities in the United States. The technology is purported to decrease medication errors that occur at the point of administration. How significantly this technology affects actual rate and severity of error is unknown. This descriptive, longitudinal research…

Blindness and Visual Impairment Profile and Rapid Assessment of Avoidable Blindness in South East Asia: Analysis of New Data. 2017 APAO Holmes Lecture.

PubMed

Das, Taraprasad

2018-03-13

The International Agency for Prevention of Blindness (IAPB) South East Asia region (SEAR) that consists of 11 countries contains 26% of the world's population (1,761,000,000). In this region 12 million are blind and 78.5 million are visually impaired. This amounts to 30% of global blindness and 32% of global visual impairment. Rapid assessment of avoidable blindness (RAAB) survey analysis. RAAB, either a repeat or a first time survey, was completed in 8 countries in this decade (2010 onwards). These include Bangladesh, Bhutan, India, Indonesia, Maldives, Sri Lanka, Thailand, and Timor Leste. Cataract is the principal cause of blindness and severe visual impairment in all countries. Refractive error is the principal cause of moderate visual impairment in 4 countries: Bangladesh, India, Maldives, and Sri Lanka; cataract continues to be the principal cause of moderate visual impairment in 4 other countries: Bhutan, Indonesia, Thailand, and Timor Leste. Outcome of cataract surgery is suboptimal in the Maldives and Timor Leste. Rigorous focus is necessary to improve cataract surgery outcomes and correction of refractive error without neglecting the quality of care. At the same time allowances must be made for care of the emerging causes of visual impairment and blindness such as glaucoma and posterior segment disorders, particularly diabetic retinopathy. Copyright 2018 Asia-Pacific Academy of Ophthalmology.

[Second victim : Critical incident stress management in clinical medicine].

PubMed

Schiechtl, B; Hunger, M S; Schwappach, D L; Schmidt, C E; Padosch, S A

2013-09-01

Critical incidents in clinical medicine can have far-reaching consequences on patient health. In cases of severe medical errors they can seriously harm the patient or even lead to death. The involvement in such an event can result in a stress reaction, a so-called acute posttraumatic stress disorder in the healthcare provider, the so-called second victim of an adverse event. Psychological distress may not only have a long lasting impact on quality of life of the physician or caregiver involved but it may also affect the ability to provide safe patient care in the aftermath of adverse events. A literature review was performed to obtain information on care giver responses to medical errors and to determine possible supportive strategies to mitigate negative consequences of an adverse event on the second victim. An internet search and a search in Medline/Pubmed for scientific studies were conducted using the key words "second victim, "medical error", "critical incident stress management" (CISM) and "critical incident stress reporting system" (CIRS). Sources from academic medical societies and public institutions which offer crisis management programs where analyzed. The data were sorted by main categories and relevance for hospitals. Analysis was carried out using descriptive measures. In disaster medicine and aviation navigation services the implementation of a CISM program is an efficient intervention to help staff to recover after a traumatic event and to return to normal functioning and behavior. Several other concepts for a clinical crisis management plan were identified. The integration of CISM and CISM-related programs in a clinical setting may provide efficient support in an acute crisis and may help the caregiver to deal effectively with future error events and employee safety.

Syntactic and semantic errors in radiology reports associated with speech recognition software.

PubMed

Ringler, Michael D; Goss, Brian C; Bartholmai, Brian J

2017-03-01

Speech recognition software can increase the frequency of errors in radiology reports, which may affect patient care. We retrieved 213,977 speech recognition software-generated reports from 147 different radiologists and proofread them for errors. Errors were classified as "material" if they were believed to alter interpretation of the report. "Immaterial" errors were subclassified as intrusion/omission or spelling errors. The proportion of errors and error type were compared among individual radiologists, imaging subspecialty, and time periods. In all, 20,759 reports (9.7%) contained errors, of which 3992 (1.9%) were material errors. Among immaterial errors, spelling errors were more common than intrusion/omission errors ( p < .001). Proportion of errors and fraction of material errors varied significantly among radiologists and between imaging subspecialties ( p < .001). Errors were more common in cross-sectional reports, reports reinterpreting results of outside examinations, and procedural studies (all p < .001). Error rate decreased over time ( p < .001), which suggests that a quality control program with regular feedback may reduce errors.

Aged-care nurses in rural Tasmanian clinical settings more likely to think hypothetical medication error would be reported and disclosed compared to hospital and community nurses.

PubMed

Carnes, Debra; Kilpatrick, Sue; Iedema, Rick

2015-12-01

This study aims to determine the likelihood that rural nurses perceive a hypothetical medication error would be reported in their workplace. This employs cross-sectional survey using hypothetical error scenario with varying levels of harm. Clinical settings in rural Tasmania. Participants were 116 eligible surveys received from registered and enrolled nurses. Frequency of responses indicating the likelihood that severe, moderate and near miss (no harm) scenario would 'always' be reported or disclosed. Eighty per cent of nurses viewed a severe error would 'always' be reported, 64.8% a moderate error and 45.7% a near-miss error. In regards to disclosure, 54.7% felt this was 'always' likely to occur for a severe error, 44.8% for a moderate error and 26.4% for a near miss. Across all levels of severity, aged-care nurses were more likely than nurses in other settings to view error to 'always' be reported (ranging from 72-96%, P = 0.010 to 0.042,) and disclosed (68-88%, P = 0.000). Those in a management role were more likely to view error to 'always' be disclosed compared to those in a clinical role (50-77.3%, P = 0.008-0.024). Further research in rural clinical settings is needed to improve the understanding of error management and disclosure. © 2015 The Authors. Australian Journal of Rural Health published by Wiley Publishing Asia Pty Ltd on behalf of National Rural Health Alliance.

Multiple Intravenous Infusions Phase 2b: Laboratory Study

PubMed Central

Pinkney, Sonia; Fan, Mark; Chan, Katherine; Koczmara, Christine; Colvin, Christopher; Sasangohar, Farzan; Masino, Caterina; Easty, Anthony; Trbovich, Patricia

2014-01-01

Background Administering multiple intravenous (IV) infusions to a single patient via infusion pump occurs routinely in health care, but there has been little empirical research examining the risks associated with this practice or ways to mitigate those risks. Objectives To identify the risks associated with multiple IV infusions and assess the impact of interventions on nurses’ ability to safely administer them. Data Sources and Review Methods Forty nurses completed infusion-related tasks in a simulated adult intensive care unit, with and without interventions (i.e., repeated-measures design). Results Errors were observed in completing common tasks associated with the administration of multiple IV infusions, including the following (all values from baseline, which was current practice): setting up and programming multiple primary continuous IV infusions (e.g., 11.7% programming errors) identifying IV infusions (e.g., 7.7% line-tracing errors) managing dead volume (e.g., 96.0% flush rate errors following IV syringe dose administration) setting up a secondary intermittent IV infusion (e.g., 11.3% secondary clamp errors) administering an IV pump bolus (e.g., 11.5% programming errors) Of 10 interventions tested, 6 (1 practice, 3 technology, and 2 educational) significantly decreased or even eliminated errors compared to baseline. Limitations The simulation of an adult intensive care unit at 1 hospital limited the ability to generalize results. The study results were representative of nurses who received training in the interventions but had little experience using them. The longitudinal effects of the interventions were not studied. Conclusions Administering and managing multiple IV infusions is a complex and risk-prone activity. However, when a patient requires multiple IV infusions, targeted interventions can reduce identified risks. A combination of standardized practice, technology improvements, and targeted education is required. PMID:26316919

Task Decomposition in Human Reliability Analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Boring, Ronald Laurids; Joe, Jeffrey Clark

2014-06-01

In the probabilistic safety assessments (PSAs) used in the nuclear industry, human failure events (HFEs) are determined as a subset of hardware failures, namely those hardware failures that could be triggered by human action or inaction. This approach is top-down, starting with hardware faults and deducing human contributions to those faults. Elsewhere, more traditionally human factors driven approaches would tend to look at opportunities for human errors first in a task analysis and then identify which of those errors is risk significant. The intersection of top-down and bottom-up approaches to defining HFEs has not been carefully studied. Ideally, both approachesmore » should arrive at the same set of HFEs. This question remains central as human reliability analysis (HRA) methods are generalized to new domains like oil and gas. The HFEs used in nuclear PSAs tend to be top-down— defined as a subset of the PSA—whereas the HFEs used in petroleum quantitative risk assessments (QRAs) are more likely to be bottom-up—derived from a task analysis conducted by human factors experts. The marriage of these approaches is necessary in order to ensure that HRA methods developed for top-down HFEs are also sufficient for bottom-up applications.« less

Claims for compensation after alleged birth asphyxia: a nationwide study covering 15 years.

PubMed

Andreasen, Stine; Backe, Bjørn; Øian, Pål

2014-02-01

To analyze compensation claims with neurological sequela or death following alleged birth asphyxia. A cohort study. A nationwide study in Norway. All claims made to The Norwegian System of Compensation to Patients (NPE) concerning sequela related to alleged birth asphyxia, between 1994 and 2008. A total of 315 claims of which 161 were awarded compensation. Examination of hospital records, experts' assessments and the decisions made by the NPE, the appeal body and courts of law. Characteristics of deliveries resulting in intrapartum asphyxia and causes of substandard care categorized in eight groups. In the 161 compensated cases, 107 children survived (96 with neurological sequela), and 54 children died. Human error was a frequent reason of substandard care, seen as inadequate fetal monitoring (50%), lack of clinical knowledge and skills (14%), noncompliance with clinical guidelines (11%), failure in referral for senior medical help (10%) and error in drug administration (4%). System errors were registered in only 3%, seen as poor organization of the department, lack of guidelines and time conflicts. The health personnel held responsible for substandard care was an obstetrician in 49% and a midwife in 46%. Substandard care is common in birth asphyxia, and human error is the cause in most cases. Inadequate fetal monitoring and lack of clinical knowledge and skills are the most frequent reasons for compensation after birth asphyxia. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

A survey of community members' perceptions of medical errors in Oman

PubMed Central

Al-Mandhari, Ahmed S; Al-Shafaee, Mohammed A; Al-Azri, Mohammed H; Al-Zakwani, Ibrahim S; Khan, Mushtaq; Al-Waily, Ahmed M; Rizvi, Syed

2008-01-01

Background Errors have been the concern of providers and consumers of health care services. However, consumers' perception of medical errors in developing countries is rarely explored. The aim of this study is to assess community members' perceptions about medical errors and to analyse the factors affecting this perception in one Middle East country, Oman. Methods Face to face interviews were conducted with heads of 212 households in two villages in North Al-Batinah region of Oman selected because of close proximity to the Sultan Qaboos University (SQU), Muscat, Oman. Participants' perceived knowledge about medical errors was assessed. Responses were coded and categorised. Analyses were performed using Pearson's χ2, Fisher's exact tests, and multivariate logistic regression model wherever appropriate. Results Seventy-eight percent (n = 165) of participants believed they knew what was meant by medical errors. Of these, 34% and 26.5% related medical errors to wrong medications or diagnoses, respectively. Understanding of medical errors was correlated inversely with age and positively with family income. Multivariate logistic regression revealed that a one-year increase in age was associated with a 4% reduction in perceived knowledge of medical errors (CI: 1% to 7%; p = 0.045). The study found that 49% of those who believed they knew the meaning of medical errors had experienced such errors. The most common consequence of the errors was severe pain (45%). Of the 165 informed participants, 49% felt that an uncaring health care professional was the main cause of medical errors. Younger participants were able to list more possible causes of medical errors than were older subjects (Incident Rate Ratio of 0.98; p < 0.001). Conclusion The majority of participants believed they knew the meaning of medical errors. Younger participants were more likely to be aware of such errors and could list one or more causes. PMID:18664245

Protocol for the PINCER trial: a cluster randomised trial comparing the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

PubMed Central

Avery, Anthony J; Rodgers, Sarah; Cantrill, Judith A; Armstrong, Sarah; Elliott, Rachel; Howard, Rachel; Kendrick, Denise; Morris, Caroline J; Murray, Scott A; Prescott, Robin J; Cresswell, Kathrin; Sheikh, Aziz

2009-01-01

Background Medication errors are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. Methods Research subject group: "At-risk" patients registered with computerised general practices in two geographical regions in England. Design: Parallel group pragmatic cluster randomised trial. Interventions: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. Primary outcome measures: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs - with a computer-recorded diagnosis of asthma being prescribed beta-blockers - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. Secondary outcome measures; These relate to a number of other examples of potentially hazardous prescribing and medicines management. Economic analysis: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. Qualitative analysis: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. Sample size: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. Discussion At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken. Trial registration Current controlled trials ISRCTN21785299 PMID:19409095

Safety culture and care: a program to prevent surgical errors.

PubMed

Hemingway, Maureen White; O'Malley, Catherine; Silvestri, Sandra

2015-04-01

Surgical errors are under scrutiny in health care as part of ensuring a culture of safety in which patients receive quality care. Hospitals use safety measures to compare their performance against industry benchmarks. To understand patient safety issues, health care providers must have processes in place to analyze and evaluate the quality of the care they provide. At one facility, efforts made to improve its quality and safety led to the development of a robust safety program with resources devoted to enhancing the culture of safety in the Perioperative Services department. Improvement initiatives included changing processes for safety reporting and performance improvement plans, adding resources and nurse roles, and creating communication strategies around adverse safety events and how to improve care. One key outcome included a 54% increase in the percentage of personnel who indicated in a survey that they would speak up if they saw something negatively affecting patient care. Copyright © 2015 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Minding the gap: Interprofessional communication during inpatient and post discharge chasm care.

PubMed

Scotten, Mitzi; Manos, Eva LaVerne; Malicoat, Allison; Paolo, Anthony M

2015-07-01

Poor communication is cited as a main cause of poor patient outcomes and errors in healthcare, and clear communication can be especially critical during transitions such as discharge. In this project, communication was standardized for clarity, and techniques were implemented to continue care from inpatient, to discharge, across the post-discharge chasm, to hand-off with the primary care provider (PCP). The interprofessional (IP) quality improvement initiative included: (1) evidence-based teamwork system; (2) in situ simulation; (3) creation of an IP model of care; and (4) innovations in use of telehealth technology to continue care post-discharge. Measures inpatient/parent satisfaction and the attitudes of the care team have improved. Traditional methods of communication and transition do not meet patient or healthcare provider needs. Communication must be standardized to be understandable and be used by the IP team. Care must continue post-discharge by utilizing technology to increase quality and continuity of care. Improving and practicing communication skills may lead to reductions in healthcare errors and readmissions, and may decrease the length of stay and improve satisfaction of care teams. Published by Elsevier Ireland Ltd.

Suffering in Silence: Medical Error and its Impact on Health Care Providers.

PubMed

Robertson, Jennifer J; Long, Brit

2018-04-01

All humans are fallible. Because physicians are human, unintentional errors unfortunately occur. While unintentional medical errors have an impact on patients and their families, they may also contribute to adverse mental and emotional effects on the involved provider(s). These may include burnout, lack of concentration, poor work performance, posttraumatic stress disorder, depression, and even suicidality. The objectives of this article are to 1) discuss the impact medical error has on involved provider(s), 2) provide potential reasons why medical error can have a negative impact on provider mental health, and 3) suggest solutions for providers and health care organizations to recognize and mitigate the adverse effects medical error has on providers. Physicians and other providers may feel a variety of adverse emotions after medical error, including guilt, shame, anxiety, fear, and depression. It is thought that the pervasive culture of perfectionism and individual blame in medicine plays a considerable role toward these negative effects. In addition, studies have found that despite physicians' desire for support after medical error, many physicians feel a lack of personal and administrative support. This may further contribute to poor emotional well-being. Potential solutions in the literature are proposed, including provider counseling, learning from mistakes without fear of punishment, discussing mistakes with others, focusing on the system versus the individual, and emphasizing provider wellness. Much of the reviewed literature is limited in terms of an emergency medicine focus or even regarding physicians in general. In addition, most studies are survey- or interview-based, which limits objectivity. While additional, more objective research is needed in terms of mitigating the effects of error on physicians, this review may help provide insight and support for those who feel alone in their attempt to heal after being involved in an adverse medical event. Unintentional medical error will likely always be a part of the medical system. However, by focusing on provider as well as patient health, we may be able to foster resilience in providers and improve care for patients in healthy, safe, and constructive environments. Copyright © 2017 Elsevier Inc. All rights reserved.

Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

PubMed Central

Panagioti, Maria; Stokes, Jonathan; Esmail, Aneez; Coventry, Peter; Cheraghi-Sohi, Sudeh; Alam, Rahul; Bower, Peter

2015-01-01

Background Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care. Methods We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: ‘active patient safety incidents’ (such as adverse drug events and medical complications) and ‘precursors of safety incidents’ (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken. Results Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for ‘active patient safety incidents’ (OR = 2.39, 95% CI = 1.40 to 3.38) and ‘precursors of safety incidents’ (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low. Conclusions The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients. PMID:26317435

Effects of sharing information on drug administration errors in pediatric wards: a pre–post intervention study

PubMed Central

Chua, Siew-Siang; Choo, Sim-Mei; Sulaiman, Che Zuraini; Omar, Asma; Thong, Meow-Keong

2017-01-01

Background and purpose Drug administration errors are more likely to reach the patient than other medication errors. The main aim of this study was to determine whether the sharing of information on drug administration errors among health care providers would reduce such problems. Patients and methods This study involved direct, undisguised observations of drug administrations in two pediatric wards of a major teaching hospital in Kuala Lumpur, Malaysia. This study consisted of two phases: Phase 1 (pre-intervention) and Phase 2 (post-intervention). Data were collected by two observers over a 40-day period in both Phase 1 and Phase 2 of the study. Both observers were pharmacy graduates: Observer 1 just completed her undergraduate pharmacy degree, whereas Observer 2 was doing her one-year internship as a provisionally registered pharmacist in the hospital under study. A drug administration error was defined as a discrepancy between the drug regimen received by the patient and that intended by the prescriber and also drug administration procedures that did not follow standard hospital policies and procedures. Results from Phase 1 of the study were analyzed, presented and discussed with the ward staff before commencement of data collection in Phase 2. Results A total of 1,284 and 1,401 doses of drugs were administered in Phase 1 and Phase 2, respectively. The rate of drug administration errors reduced significantly from Phase 1 to Phase 2 (44.3% versus 28.6%, respectively; P<0.001). Logistic regression analysis showed that the adjusted odds of drug administration errors in Phase 1 of the study were almost three times that in Phase 2 (P<0.001). The most common types of errors were incorrect administration technique and incorrect drug preparation. Nasogastric and intravenous routes of drug administration contributed significantly to the rate of drug administration errors. Conclusion This study showed that sharing of the types of errors that had occurred was significantly associated with a reduction in drug administration errors. PMID:28356748

The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis

PubMed Central

2014-01-01

Background The Health Information Technology for Economic and Clinical Health (HITECH) Act subsidizes implementation by hospitals of electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries caused by medication errors (preventable adverse drug events, pADEs). Effects on pADEs have not been rigorously quantified, and effects on medication errors have been variable. The objectives of this analysis were to assess the effectiveness of CPOE at reducing pADEs in hospital-related settings, and examine reasons for heterogeneous effects on medication errors. Methods Articles were identified using MEDLINE, Cochrane Library, Econlit, web-based databases, and bibliographies of previous systematic reviews (September 2013). Eligible studies compared CPOE with paper-order entry in acute care hospitals, and examined diverse pADEs or medication errors. Studies on children or with limited event-detection methods were excluded. Two investigators extracted data on events and factors potentially associated with effectiveness. We used random effects models to pool data. Results Sixteen studies addressing medication errors met pooling criteria; six also addressed pADEs. Thirteen studies used pre-post designs. Compared with paper-order entry, CPOE was associated with half as many pADEs (pooled risk ratio (RR) = 0.47, 95% CI 0.31 to 0.71) and medication errors (RR = 0.46, 95% CI 0.35 to 0.60). Regarding reasons for heterogeneous effects on medication errors, five intervention factors and two contextual factors were sufficiently reported to support subgroup analyses or meta-regression. Differences between commercial versus homegrown systems, presence and sophistication of clinical decision support, hospital-wide versus limited implementation, and US versus non-US studies were not significant, nor was timing of publication. Higher baseline rates of medication errors predicted greater reductions (P < 0.001). Other context and implementation variables were seldom reported. Conclusions In hospital-related settings, implementing CPOE is associated with a greater than 50% decline in pADEs, although the studies used weak designs. Decreases in medication errors are similar and robust to variations in important aspects of intervention design and context. This suggests that CPOE implementation, as subsidized under the HITECH Act, may benefit public health. More detailed reporting of the context and process of implementation could shed light on factors associated with greater effectiveness. PMID:24894078

Review of current GPS methodologies for producing accurate time series and their error sources

NASA Astrophysics Data System (ADS)

He, Xiaoxing; Montillet, Jean-Philippe; Fernandes, Rui; Bos, Machiel; Yu, Kegen; Hua, Xianghong; Jiang, Weiping

2017-05-01

The Global Positioning System (GPS) is an important tool to observe and model geodynamic processes such as plate tectonics and post-glacial rebound. In the last three decades, GPS has seen tremendous advances in the precision of the measurements, which allow researchers to study geophysical signals through a careful analysis of daily time series of GPS receiver coordinates. However, the GPS observations contain errors and the time series can be described as the sum of a real signal and noise. The signal itself can again be divided into station displacements due to geophysical causes and to disturbing factors. Examples of the latter are errors in the realization and stability of the reference frame and corrections due to ionospheric and tropospheric delays and GPS satellite orbit errors. There is an increasing demand on detecting millimeter to sub-millimeter level ground displacement signals in order to further understand regional scale geodetic phenomena hence requiring further improvements in the sensitivity of the GPS solutions. This paper provides a review spanning over 25 years of advances in processing strategies, error mitigation methods and noise modeling for the processing and analysis of GPS daily position time series. The processing of the observations is described step-by-step and mainly with three different strategies in order to explain the weaknesses and strengths of the existing methodologies. In particular, we focus on the choice of the stochastic model in the GPS time series, which directly affects the estimation of the functional model including, for example, tectonic rates, seasonal signals and co-seismic offsets. Moreover, the geodetic community continues to develop computational methods to fully automatize all phases from analysis of GPS time series. This idea is greatly motivated by the large number of GPS receivers installed around the world for diverse applications ranging from surveying small deformations of civil engineering structures (e.g., subsidence of the highway bridge) to the detection of particular geophysical signals.

Cognitive processes in anesthesiology decision making.

PubMed

Stiegler, Marjorie Podraza; Tung, Avery

2014-01-01

The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.

Effects of health care provider work hours and sleep deprivation on safety and performance.

PubMed

Lockley, Steven W; Barger, Laura K; Ayas, Najib T; Rothschild, Jeffrey M; Czeisler, Charles A; Landrigan, Christopher P

2007-11-01

There has been increasing interest in the impact of resident-physician and nurse work hours on patient safety. The evidence demonstrates that work schedules have a profound effect on providers' sleep and performance, as well as on their safety and that of their patients. Nurses working shifts greater than 12.5 hours are at significantly increased risk of experiencing decreased vigilance on the job, suffering an occupational injury, or making a medical error. Physicians-in-training working traditional > 24-hour on-call shifts are at greatly increased risk of experiencing an occupational sharps injury or a motor vehicle crash on the drive home from work and of making a serious or even fatal medical error. As compared to when working 16-hours shifts, on-call residents have twice as many attentional failures when working overnight and commit 36% more serious medical errors. They also report making 300% more fatigue-related medical errors that lead to a patient's death. The weight of evidence strongly suggests that extended-duration work shifts significantly increase fatigue and impair performance and safety. From the standpoint of both providers and patients, the hours routinely worked by health care providers in the United States are unsafe. To reduce the unacceptably high rate of preventable fatigue-related medical error and injuries among health care workers, the United States must establish and enforce safe work-hour limits.

Impact of Frequent Interruption on Nurses' Patient-Controlled Analgesia Programming Performance.

PubMed

Campoe, Kristi R; Giuliano, Karen K

2017-12-01

The purpose was to add to the body of knowledge regarding the impact of interruption on acute care nurses' cognitive workload, total task completion times, nurse frustration, and medication administration error while programming a patient-controlled analgesia (PCA) pump. Data support that the severity of medication administration error increases with the number of interruptions, which is especially critical during the administration of high-risk medications. Bar code technology, interruption-free zones, and medication safety vests have been shown to decrease administration-related errors. However, there are few published data regarding the impact of number of interruptions on nurses' clinical performance during PCA programming. Nine acute care nurses completed three PCA pump programming tasks in a simulation laboratory. Programming tasks were completed under three conditions where the number of interruptions varied between two, four, and six. Outcome measures included cognitive workload (six NASA Task Load Index [NASA-TLX] subscales), total task completion time (seconds), nurse frustration (NASA-TLX Subscale 6), and PCA medication administration error (incorrect final programming). Increases in the number of interruptions were associated with significant increases in total task completion time ( p = .003). We also found increases in nurses' cognitive workload, nurse frustration, and PCA pump programming errors, but these increases were not statistically significant. Complex technology use permeates the acute care nursing practice environment. These results add new knowledge on nurses' clinical performance during PCA pump programming and high-risk medication administration.

Neonatal infrared thermography imaging: Analysis of heat flux during different clinical scenarios

NASA Astrophysics Data System (ADS)

Abbas, Abbas K.; Heimann, Konrad; Blazek, Vladimir; Orlikowsky, Thorsten; Leonhardt, Steffen

2012-11-01

IntroductionAn accurate skin temperature measurement of Neonatal Infrared Thermography (NIRT) imaging requires an appropriate calibration process for compensation of external effects (e.g. variation of environmental temperature, variable air velocity or humidity). Although modern infrared cameras can perform such calibration, an additional compensation is required for highly accurate thermography. This compensation which corrects any temperature drift should occur during the NIRT imaging process. We introduce a compensation technique which is based on modeling the physical interactions within the measurement scene and derived the detected temperature signal of the object. Materials and methodsIn this work such compensation was performed for different NIRT imaging application in neonatology (e.g. convective incubators, kangaroo mother care (KMC), and an open radiant warmer). The spatially distributed temperatures of 12 preterm infants (average gestation age 31 weeks) were measured under these different infant care arrangements (i.e. closed care system like a convective incubator, and open care system like kangaroo mother care, and open radiant warmer). ResultsAs errors in measurement of temperature were anticipated, a novel compensation method derived from infrared thermography of the neonate's skin was developed. Moreover, the differences in temperature recording for the 12 preterm infants varied from subject to subject. This variation could be arising from individual experimental setting applied to the same region of interest over the neonate's body. The experimental results for the model-based corrections is verified over the selected patient group. ConclusionThe proposed technique relies on applying model-based correction to the measured temperature and reducing extraneous errors during NIRT. This application specific method is based on different heat flux compartments present in neonatal thermography scene. Furthermore, these results are considered to be groundwork for further investigation, especially when using NIRT imaging arrangement with additional compensation settings together with reference temperature measurements.

Development and validity of a method for the evaluation of printed education material

PubMed Central

Castro, Mauro Silveira; Pilger, Diogo; Fuchs, Flávio Danni; Ferreira, Maria Beatriz Cardoso

Objectives To develop and study the validity of an instrument for evaluation of Printed Education Materials (PEM); to evaluate the use of acceptability indices; to identify possible influences of professional aspects. Methods An instrument for PEM evaluation was developed which included tree steps: domain identification, item generation and instrument design. A reading to easy PEM was developed for education of patient with systemic hypertension and its treatment with hydrochlorothiazide. Construct validity was measured based on previously established errors purposively introduced into the PEM, which served as extreme groups. An acceptability index was applied taking into account the rate of professionals who should approve each item. Participants were 10 physicians (9 men) and 5 nurses (all women). Results Many professionals identified intentional errors of crude character. Few participants identified errors that needed more careful evaluation, and no one detected the intentional error that required literature analysis. Physicians considered as acceptable 95.8% of the items of the PEM, and nurses 29.2%. The differences between the scoring were statistically significant in 27% of the items. In the overall evaluation, 66.6% were considered as acceptable. The analysis of each item revealed a behavioral pattern for each professional group. Conclusions The use of instruments for evaluation of printed education materials is required and may improve the quality of the PEM available for the patients. Not always are the acceptability indices totally correct or represent high quality of information. The professional experience, the practice pattern, and perhaps the gendre of the reviewers may influence their evaluation. An analysis of the PEM by professionals in communication, in drug information, and patients should be carried out to improve the quality of the proposed material. PMID:25214924

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report

PubMed Central

Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio

2012-01-01

Objective Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Design and setting Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. Primary outcome To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. Results In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. Conclusions FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children. PMID:23253870

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.

PubMed

Lago, Paola; Bizzarri, Giancarlo; Scalzotto, Francesca; Parpaiola, Antonella; Amigoni, Angela; Putoto, Giovanni; Perilongo, Giorgio

2012-01-01

Administering medication to hospitalised infants and children is a complex process at high risk of error. Failure mode and effect analysis (FMEA) is a proactive tool used to analyse risks, identify failures before they happen and prioritise remedial measures. To examine the hazards associated with the process of drug delivery to children, we performed a proactive risk-assessment analysis. Five multidisciplinary teams, representing different divisions of the paediatric department at Padua University Hospital, were trained to analyse the drug-delivery process, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure and plan changes in practices. To identify higher-priority potential failure modes as defined by RPNs and planning changes in clinical practice to reduce the risk of patients harm and improve safety in the process of medication use in children. In all, 37 higher-priority potential failure modes and 71 associated causes and effects were identified. The highest RPNs related (>48) mainly to errors in calculating drug doses and concentrations. Many of these failure modes were found in all the five units, suggesting the presence of common targets for improvement, particularly in enhancing the safety of prescription and preparation of endovenous drugs. The introductions of new activities in the revised process of administering drugs allowed reducing the high-risk failure modes of 60%. FMEA is an effective proactive risk-assessment tool useful to aid multidisciplinary groups in understanding a process care and identifying errors that may occur, prioritising remedial interventions and possibly enhancing the safety of drug delivery in children.

Double checking medicines: defence against error or contributory factor?

PubMed

Armitage, Gerry

2008-08-01

The double checking of medicines in health care is a contestable procedure. It occupies an obvious position in health care practice and is understood to be an effective defence against medication error but the process is variable and the outcomes have not been exposed to testing. This paper presents an appraisal of the process using data from part of a larger study on the contributory factors in medication errors and their reporting. Previous research studies are reviewed; data are analysed from a review of 991 drug error reports and a subsequent series of 40 in-depth interviews with health professionals in an acute hospital in northern England. The incident reports showed that errors occurred despite double checking but that action taken did not appear to investigate the checking process. Most interview participants (34) talked extensively about double checking but believed the process to be inconsistent. Four key categories were apparent: deference to authority, reduction of responsibility, automatic processing and lack of time. Solutions to the problems were also offered, which are discussed with several recommendations. Double checking medicines should be a selective and systematic procedure informed by key principles and encompassing certain behaviours. Psychological research may be instructive in reducing checking errors but the aviation industry may also have a part to play in increasing error wisdom and reducing risk.

[Medication errors in a neonatal unit: One of the main adverse events].

PubMed

Esqué Ruiz, M T; Moretones Suñol, M G; Rodríguez Miguélez, J M; Sánchez Ortiz, E; Izco Urroz, M; de Lamo Camino, M; Figueras Aloy, J

2016-04-01

Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. An analysis was performed on the ME declared in a neonatal unit. A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety. Copyright © 2015 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.

Comparison of the clinical information provided by the FreeStyle Navigator continuous interstitial glucose monitor versus traditional blood glucose readings.

PubMed

McGarraugh, Geoffrey V; Clarke, William L; Kovatchev, Boris P

2010-05-01

The purpose of the analysis was to compare the clinical utility of data from traditional self-monitoring of blood glucose (SMBG) to that of continuous glucose monitoring (CGM). A clinical study of the clinical accuracy of the FreeStyle Navigator CGM System (Abbott Diabetes Care, Alameda, CA), which includes SMBG capabilities, was conducted by comparison to the YSI blood glucose analyzer (YSI Inc., Yellow Springs, OH) using 58 subjects with type 1 diabetes. The Continuous Glucose-Error Grid Analysis (CG-EGA) was used as the analytical tool. Using CG-EGA, the "clinically accurate," "benign errors," and "clinical errors" were 86.8%, 8.7%, and 4.5% for SMBG and 92.7%, 3.7%, and 3.6% for CGM, respectively. If blood glucose is viewed as a process in time, SMBG would provide accurate information about this process 86.8% of the time, whereas CGM would provide accurate information about this process 92.7% of the time (P < 0.0001). In the hypoglycemic range, however, SMBG is more accurate as the "clinically accurate," "benign errors," and "clinical errors" were 83.5%, 6.4%, and 10.1% for SMBG and 57.1%, 8.4%, and 34.5% (P < 0.0001) for CGM, respectively. While SMBG produces more accurate instantaneous glucose values than CGM, control of blood glucose involves a system in flux, and CGM provides more detailed insight into the dynamics of that system. In the normal and elevated glucose ranges, the additional information about the direction and rate of glucose change provided by the FreeStyle Navigator CGM System increases the ability to make correct clinical decisions when compared to episodic SMBG tests.

Geospatial distribution modeling and determining suitability of groundwater quality for irrigation purpose using geospatial methods and water quality index (WQI) in Northern Ethiopia

NASA Astrophysics Data System (ADS)

Gidey, Amanuel

2018-06-01

Determining suitability and vulnerability of groundwater quality for irrigation use is a key alarm and first aid for careful management of groundwater resources to diminish the impacts on irrigation. This study was conducted to determine the overall suitability of groundwater quality for irrigation use and to generate their spatial distribution maps in Elala catchment, Northern Ethiopia. Thirty-nine groundwater samples were collected to analyze and map the water quality variables. Atomic absorption spectrophotometer, ultraviolet spectrophotometer, titration and calculation methods were used for laboratory groundwater quality analysis. Arc GIS, geospatial analysis tools, semivariogram model types and interpolation methods were used to generate geospatial distribution maps. Twelve and eight water quality variables were used to produce weighted overlay and irrigation water quality index models, respectively. Root-mean-square error, mean square error, absolute square error, mean error, root-mean-square standardized error, measured values versus predicted values were used for cross-validation. The overall weighted overlay model result showed that 146 km2 areas are highly suitable, 135 km2 moderately suitable and 60 km2 area unsuitable for irrigation use. The result of irrigation water quality index confirms 10.26% with no restriction, 23.08% with low restriction, 20.51% with moderate restriction, 15.38% with high restriction and 30.76% with the severe restriction for irrigation use. GIS and irrigation water quality index are better methods for irrigation water resources management to achieve a full yield irrigation production to improve food security and to sustain it for a long period, to avoid the possibility of increasing environmental problems for the future generation.

Validation of cardiac output studies from the Mostcare compared to a pulmonary artery catheter in septic patients.

PubMed

Gopal, S; Do, T; Pooni, J S; Martinelli, G

2014-03-01

The Mostcare monitor is a non-invasive cardiac output monitor. It has been well validated in cardiac surgical patients but there is limited evidence on its use in patients with severe sepsis and septic shock. The study included the first 22 consecutive patients with severe sepsis and septic shock in whom the floatation of a pulmonary artery catheter was deemed necessary to guide clinical management. Cardiac output measurements including cardiac output, cardiac index and stroke volume were simultaneously calculated and recorded from a thermodilution pulmonary artery catheter and from the Mostcare monitor respectively. The two methods of measuring cardiac output were compared by Bland-Altman statistics and linear regression analysis. A percentage error of less than 30% was defined as acceptable for this study. Bland-Altman analysis for cardiac output showed a Bias of 0.31 L.min-1, precision (=SD) of 1.97 L.min-1 and a percentage error of 62.54%. For Cardiac Index the bias was 0.21 L.min-1.m-2, precision of 1.10 L.min-1.m-2 and a percentage error of 64%. For stroke volume the bias was 5 mL, precision of 24.46 mL and percentage error of 70.21%. Linear regression produced a correlation coefficient r2 for cardiac output, cardiac index, and stroke volume, of 0.403, 0.306, and 0.3 respectively. Compared to thermodilution cardiac output, cardiac output studies obtained from the Mostcare monitor have an unacceptably high error rate. The Mostcare monitor demonstrated to be an unreliable monitoring device to measure cardiac output in patients with severe sepsis and septic shock on an intensive care unit.

A content validated questionnaire for assessment of self reported venous blood sampling practices

PubMed Central

2012-01-01

Background Venous blood sampling is a common procedure in health care. It is strictly regulated by national and international guidelines. Deviations from guidelines due to human mistakes can cause patient harm. Validated questionnaires for health care personnel can be used to assess preventable "near misses"--i.e. potential errors and nonconformities during venous blood sampling practices that could transform into adverse events. However, no validated questionnaire that assesses nonconformities in venous blood sampling has previously been presented. The aim was to test a recently developed questionnaire in self reported venous blood sampling practices for validity and reliability. Findings We developed a questionnaire to assess deviations from best practices during venous blood sampling. The questionnaire contained questions about patient identification, test request management, test tube labeling, test tube handling, information search procedures and frequencies of error reporting. For content validity, the questionnaire was confirmed by experts on questionnaires and venous blood sampling. For reliability, test-retest statistics were used on the questionnaire answered twice. The final venous blood sampling questionnaire included 19 questions out of which 9 had in total 34 underlying items. It was found to have content validity. The test-retest analysis demonstrated that the items were generally stable. In total, 82% of the items fulfilled the reliability acceptance criteria. Conclusions The questionnaire could be used for assessment of "near miss" practices that could jeopardize patient safety and gives several benefits instead of assessing rare adverse events only. The higher frequencies of "near miss" practices allows for quantitative analysis of the effect of corrective interventions and to benchmark preanalytical quality not only at the laboratory/hospital level but also at the health care unit/hospital ward. PMID:22260505

A content validated questionnaire for assessment of self reported venous blood sampling practices.

PubMed

Bölenius, Karin; Brulin, Christine; Grankvist, Kjell; Lindkvist, Marie; Söderberg, Johan

2012-01-19

Venous blood sampling is a common procedure in health care. It is strictly regulated by national and international guidelines. Deviations from guidelines due to human mistakes can cause patient harm. Validated questionnaires for health care personnel can be used to assess preventable "near misses"--i.e. potential errors and nonconformities during venous blood sampling practices that could transform into adverse events. However, no validated questionnaire that assesses nonconformities in venous blood sampling has previously been presented. The aim was to test a recently developed questionnaire in self reported venous blood sampling practices for validity and reliability. We developed a questionnaire to assess deviations from best practices during venous blood sampling. The questionnaire contained questions about patient identification, test request management, test tube labeling, test tube handling, information search procedures and frequencies of error reporting. For content validity, the questionnaire was confirmed by experts on questionnaires and venous blood sampling. For reliability, test-retest statistics were used on the questionnaire answered twice. The final venous blood sampling questionnaire included 19 questions out of which 9 had in total 34 underlying items. It was found to have content validity. The test-retest analysis demonstrated that the items were generally stable. In total, 82% of the items fulfilled the reliability acceptance criteria. The questionnaire could be used for assessment of "near miss" practices that could jeopardize patient safety and gives several benefits instead of assessing rare adverse events only. The higher frequencies of "near miss" practices allows for quantitative analysis of the effect of corrective interventions and to benchmark preanalytical quality not only at the laboratory/hospital level but also at the health care unit/hospital ward.

Medication Errors in Patients with Enteral Feeding Tubes in the Intensive Care Unit.

PubMed

Sohrevardi, Seyed Mojtaba; Jarahzadeh, Mohammad Hossein; Mirzaei, Ehsan; Mirjalili, Mahtabalsadat; Tafti, Arefeh Dehghani; Heydari, Behrooz

2017-01-01

Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems. A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines. Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively. In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients' pharmacotherapy, and more attention should be paid to this issue.

Medical errors; causes, consequences, emotional response and resulting behavioral change

PubMed Central

Bari, Attia; Khan, Rehan Ahmed; Rathore, Ahsan Waheed

2016-01-01

Objective: To determine the causes of medical errors, the emotional and behavioral response of pediatric medicine residents to their medical errors and to determine their behavior change affecting their future training. Methods: One hundred thirty postgraduate residents were included in the study. Residents were asked to complete questionnaire about their errors and responses to their errors in three domains: emotional response, learning behavior and disclosure of the error. The names of the participants were kept confidential. Data was analyzed using SPSS version 20. Results: A total of 130 residents were included. Majority 128(98.5%) of these described some form of error. Serious errors that occurred were 24(19%), 63(48%) minor, 24(19%) near misses,2(2%) never encountered an error and 17(12%) did not mention type of error but mentioned causes and consequences. Only 73(57%) residents disclosed medical errors to their senior physician but disclosure to patient’s family was negligible 15(11%). Fatigue due to long duty hours 85(65%), inadequate experience 66(52%), inadequate supervision 58(48%) and complex case 58(45%) were common causes of medical errors. Negative emotions were common and were significantly associated with lack of knowledge (p=0.001), missing warning signs (p=<0.001), not seeking advice (p=0.003) and procedural complications (p=0.001). Medical errors had significant impact on resident’s behavior; 119(93%) residents became more careful, increased advice seeking from seniors 109(86%) and 109(86%) started paying more attention to details. Intrinsic causes of errors were significantly associated with increased information seeking behavior and vigilance (p=0.003) and (p=0.01) respectively. Conclusion: Medical errors committed by residents have inadequate disclosure to senior physicians and result in negative emotions but there was positive change in their behavior, which resulted in improvement in their future training and patient care. PMID:27375682

Bullying among nursing staff: relationship with psychological/behavioral responses of nurses and medical errors.

PubMed

Wright, Whitney; Khatri, Naresh

2015-01-01

The aim of this article is to examine the relationship between three types of bullying (person-related, work-related, and physically intimidating) with two types of outcomes (psychological/behavioral responses of nurses and medical errors). In addition, it investigates if the three types of bullying behaviors vary with age or gender of nurses and if the extent of bullying varies across different facilities in an institution. Nurses play an integral role in achieving safe and effective health care. To ensure nurses are functioning at their optimal level, health care organizations need to reduce negative components that impact nurses' job performance and their mental and physical health. Mitigating bullying from the workplace may be necessary to create and maintain a high-performing, caring, and safe hospital culture. Using an internal e-mail system, an e-mail requesting the participants to complete the questionnaire on Survey Monkey was sent to a sample of 1,078 nurses employed across three facilities at a university hospital system in the Midwest. Two hundred forty-one completed questionnaires were received with a response rate of 23%. Bullying was measured utilizing the Negative Acts Questionnaire-Revised (NAQ-R). Outcomes (psychological/behavioral responses of nurses and medical errors) were measured using Rosenstein and O'Daniel's (2008) modified scales. Person-related bullying showed significant positive relationships with psychological/behavioral responses and medical errors. Work-related bullying showed a significant positive relationship with psychological/behavioral responses, but not with medical errors. Physically intimidating bullying did not show a significant relationship to either outcome. Whereas person-related bullying was found to be negatively associated with age of nurses, physically intimidating bullying was positively associated with age. Male nurses experienced higher work-related bullying than female nurses. Findings from this study suggest that bullying behaviors exist and affect psychological/behavioral responses of nurses such as stress and anxiety and medical errors. Health care organizations should identify bullying behaviors and implement bullying prevention strategies to reduce those behaviors and the adverse effects that they may have on psychological/behavioral responses of nurses and medical errors.

Undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkship.

PubMed

Lee, Hoo-Yeon; Hahm, Myung-Il; Lee, Sang Gyu

2018-04-04

The purpose of this study was to examine undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkships. Cross-sectional study administered in face-to-face interviews using modified the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS) from three colleges of medicine in Korea. We assessed medical students' perceptions of the cultures ('safety', 'teamwork', and 'error disclosure'), 'behavioural intentions' concerning patient safety issues and 'overall patient safety'. Confirmatory factor analysis and Spearman's correlation analyses was performed. In total, 194(91.9%) of the 211 third-year undergraduate students participated. 78% of medical students reported that the quality of care received by patients was impacted by teamwork during clinical rotations. Regarding error disclosure, positive scores ranged from 10% to 74%. Except for one question asking whether the disclosure of medical errors was an important component of patient safety (74%), the percentages of positive scores for all the other questions were below 20%. 41.2% of medical students have intention to disclose it when they saw a medical error committed by another team member. Many students had difficulty speaking up about medical errors. Error disclosure guidelines and educational efforts aimed at developing sophisticated communication skills are needed. This study may serve as a reference for other institutions planning patient safety education in their curricula. Assessing student perceptions of safety culture can provide clerkship directors and clinical service chiefs with information that enhances the educational environment and promotes patient safety.

Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model.

PubMed

Vellone, Ercole; Pancani, Luca; Greco, Andrea; Steca, Patrizia; Riegel, Barbara

2016-08-01

Cognitive impairment can reduce the self-care abilities of heart failure patients. Theory and preliminary evidence suggest that self-care confidence may mediate the relationship between cognition and self-care, but further study is needed to validate this finding. The aim of this study was to test the mediating role of self-care confidence between specific cognitive domains and heart failure self-care. Secondary analysis of data from a descriptive study. Three out-patient sites in Pennsylvania and Delaware, USA. A sample of 280 adults with chronic heart failure, 62 years old on average and mostly male (64.3%). Data on heart failure self-care and self-care confidence were collected with the Self-Care of Heart Failure Index 6.2. Data on cognition were collected by trained research assistants using a neuropsychological test battery measuring simple and complex attention, processing speed, working memory, and short-term memory. Sociodemographic data were collected by self-report. Clinical information was abstracted from the medical record. Mediation analysis was performed with structural equation modeling and indirect effects were evaluated with bootstrapping. Most participants had at least 1 impaired cognitive domain. In mediation models, self-care confidence consistently influenced self-care and totally mediated the relationship between simple attention and self-care and between working memory and self-care (comparative fit index range: .929-.968; root mean squared error of approximation range: .032-.052). Except for short-term memory, which had a direct effect on self-care maintenance, the other cognitive domains were unrelated to self-care. Self-care confidence appears to be an important factor influencing heart failure self-care even in patients with impaired cognition. As few studies have successfully improved cognition, interventions addressing confidence should be considered as a way to improve self-care in this population. Copyright © 2016 Elsevier Ltd. All rights reserved.

Educational intervention together with an on-line quality control program achieve recommended analytical goals for bedside blood glucose monitoring in a 1200-bed university hospital.

PubMed

Sánchez-Margalet, Víctor; Rodriguez-Oliva, Manuel; Sánchez-Pozo, Cristina; Fernández-Gallardo, María Francisca; Goberna, Raimundo

2005-01-01

Portable meters for blood glucose concentrations are used at the patients bedside, as well as by patients for self-monitoring of blood glucose. Even though most devices have important technological advances that decrease operator error, the analytical goals proposed for the performance of glucose meters have been recently changed by the American Diabetes Association (ADA) to reach <5% analytical error and <7.9% total error. We studied 80 meters throughout the Virgen Macarena Hospital and we found most devices with performance error higher than 10%. The aim of the present study was to establish a new system to control portable glucose meters together with an educational program for nurses in a 1200-bed University Hospital to achieve recommended analytical goals, so that we could improve the quality of diabetes care. We used portable glucose meters connected on-line to the laboratory after an educational program for nurses with responsibilities in point-of-care testing. We evaluated the system by assessing total error of the glucometers using high- and low-level glucose control solutions. In a period of 6 months, we collected data from 5642 control samples obtained by 14 devices (Precision PCx) directly from the control program (QC manager). The average total error for the low-level glucose control (2.77 mmol/l) was 6.3% (range 5.5-7.6%), and even lower for the high-level glucose control (16.66 mmol/l), at 4.8% (range 4.1-6.5%). In conclusion, the performance of glucose meters used in our University Hospital with more than 1000 beds not only improved after the intervention, but the meters achieved the analytical goals of the suggested ADA/National Academy of Clinical Biochemistry criteria for total error (<7.9% in the range 2.77-16.66 mmol/l glucose) and optimal total error for high glucose concentrations of <5%, which will improve the quality of care of our patients.

Technical Note: Introduction of variance component analysis to setup error analysis in radiotherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Matsuo, Yukinori, E-mail: ymatsuo@kuhp.kyoto-u.ac.

Purpose: The purpose of this technical note is to introduce variance component analysis to the estimation of systematic and random components in setup error of radiotherapy. Methods: Balanced data according to the one-factor random effect model were assumed. Results: Analysis-of-variance (ANOVA)-based computation was applied to estimate the values and their confidence intervals (CIs) for systematic and random errors and the population mean of setup errors. The conventional method overestimates systematic error, especially in hypofractionated settings. The CI for systematic error becomes much wider than that for random error. The ANOVA-based estimation can be extended to a multifactor model considering multiplemore » causes of setup errors (e.g., interpatient, interfraction, and intrafraction). Conclusions: Variance component analysis may lead to novel applications to setup error analysis in radiotherapy.« less

Defining and measuring patient safety.

PubMed

Pronovost, Peter J; Thompson, David A; Holzmueller, Christine G; Lubomski, Lisa H; Morlock, Laura L

2005-01-01

Despite the growing demand for improved safety in health care, debate remains regarding the magnitude of the problem and the degree to which harm is preventable. To a great extent, this debate stems from variation in the definition and methods for measuring safety, its "shadow" error, and the degree of preventability. This article reviews the definition of safety and error, discusses approaches to measuring safety, and provides a framework for investigating incidents that unveils how the systems under which care is delivered may contribute to adverse incidents.

Patient safety culture in obstetrics and gynecology and neonatology units: the nurses' and the midwives' opinion.

PubMed

Ribeliene, Janina; Blazeviciene, Aurelija; Nadisauskiene, Ruta Jolanta; Tameliene, Rasa; Kudreviciene, Ausrele; Nedzelskiene, Irena; Macijauskiene, Jurate

2018-04-22

Patients treated in health care facilities that provide services in the fields of obstetrics, gynecology, and neonatology are especially vulnerable. Large multidisciplinary teams of physicians, multiple invasive and noninvasive diagnostic and therapeutic procedures, and the use of advanced technologies increase the probability of adverse events. The evaluation of knowledge about patient safety culture among nurses and midwives working in such units and the identification of critical areas at a health care institution would reduce the number of adverse events and improve patient safety. The aim of the study was to evaluate the opinion of nurses and midwives working in clinical departments that provide services in the fields of obstetrics, gynecology, and neonatology about patient safety culture and to explore potential predictors for the overall perception of safety. We used the Hospital Survey on Patient Safety Culture (HSOPSC) to evaluate nurses' and midwives' opinion about patient safety issues. The overall response rate in the survey was 100% (n = 233). The analysis of the dimensions of safety on the unit level showed that the respondents' most positive evaluations were in the Organizational Learning - Continuous Improvement (73.2%) and Feedback and Communication about Error (66.8%) dimensions, and the most negative evaluations in the Non-punitive Response to Error (33.5%) and Staffing (44.6%) dimensions. On the hospital level, the evaluation of the safety dimensions ranged between 41.4 and 56.8%. The percentage of positive responses in the outcome dimensions Frequency of Events Reported was 82.4%. We found a significant association between the outcome dimension Frequency of Events Reported and the Hospital Management Support for Patient Safety and Feedback and Communication about Error Dimensions. On the hospital level, the critical domains in health care facilities that provide services in the fields of obstetrics, gynecology, and neonatology were Teamwork Across Hospital Units, and on the unit level - Communication Openness, Teamwork Within Units, Non-punitive Response to Error, and Staffing. The remaining domains were seen as having a potential for improvement.

Medical errors and uncertainty in primary healthcare: A comparative study of coping strategies among young and experienced GPs

PubMed Central

Kuikka, Liisa; Pitkälä, Kaisu

2014-01-01

Abstract Objective. To study coping differences between young and experienced GPs in primary care who experience medical errors and uncertainty. Design. Questionnaire-based survey (self-assessment) conducted in 2011. Setting. Finnish primary practice offices in Southern Finland. Subjects. Finnish GPs engaged in primary health care from two different respondent groups: young (working experience ≤ 5years, n = 85) and experienced (working experience > 5 years, n = 80). Main outcome measures. Outcome measures included experiences and attitudes expressed by the included participants towards medical errors and tolerance of uncertainty, their coping strategies, and factors that may influence (positively or negatively) sources of errors. Results. In total, 165/244 GPs responded (response rate: 68%). Young GPs expressed significantly more often fear of committing a medical error (70.2% vs. 48.1%, p = 0.004) and admitted more often than experienced GPs that they had committed a medical error during the past year (83.5% vs. 68.8%, p = 0.026). Young GPs were less prone to apologize to a patient for an error (44.7% vs. 65.0%, p = 0.009) and found, more often than their more experienced colleagues, on-site consultations and electronic databases useful for avoiding mistakes. Conclusion. Experienced GPs seem to better tolerate uncertainty and also seem to fear medical errors less than their young colleagues. Young and more experienced GPs use different coping strategies for dealing with medical errors. Implications. When GPs become more experienced, they seem to get better at coping with medical errors. Means to support these skills should be studied in future research. PMID:24914458

Analysis of environmental regulatory proposals: Its your chance to influence policy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Veil, J.A.

1994-03-02

As part of the regulatory development process, the US Envirorunental Protection Agency (EPA) collects data, makes various assumptions about the data, and analyzes the data. Although EPA acts in good faith, the agency cannot always be aware of all relevant data, make only appropriate assumptions, and use applicable analytical methods. Regulated industries must carefully must carefully review every component of the regulatory decision-making process to identify misunderstandings and errors and to supply additional data that is relevant to the regulatory action. This paper examines three examples of how EPA`s data, assumptions, and analytical methods have been critiqued. The first twomore » examples involve EPA`s cost-effectiveness (CE) analyses prepared for the offshore oil and gas effluent limitations guidelines and as part of EPA Region 6`s general permit for coastal waters of Texas and Louisiana. A CE analysis regulations to the incremental amount of pollutants that would be removed by the recommended treatment processes. The third example, although not involving a CE analysis, demonstrates how the use of non-representative data can influence the outcome of an analysis.« less

Conducting Privacy-Preserving Multivariable Propensity Score Analysis When Patient Covariate Information Is Stored in Separate Locations.

PubMed

Bohn, Justin; Eddings, Wesley; Schneeweiss, Sebastian

2017-03-15

Distributed networks of health-care data sources are increasingly being utilized to conduct pharmacoepidemiologic database studies. Such networks may contain data that are not physically pooled but instead are distributed horizontally (separate patients within each data source) or vertically (separate measures within each data source) in order to preserve patient privacy. While multivariable methods for the analysis of horizontally distributed data are frequently employed, few practical approaches have been put forth to deal with vertically distributed health-care databases. In this paper, we propose 2 propensity score-based approaches to vertically distributed data analysis and test their performance using 5 example studies. We found that these approaches produced point estimates close to what could be achieved without partitioning. We further found a performance benefit (i.e., lower mean squared error) for sequentially passing a propensity score through each data domain (called the "sequential approach") as compared with fitting separate domain-specific propensity scores (called the "parallel approach"). These results were validated in a small simulation study. This proof-of-concept study suggests a new multivariable analysis approach to vertically distributed health-care databases that is practical, preserves patient privacy, and warrants further investigation for use in clinical research applications that rely on health-care databases. © The Author 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

PubMed

Heron, Claire

2017-04-27

Intravenous (IV) drug administration, especially with 'smart pumps', is complex and susceptible to errors. Although errors can occur at any stage of the IV medication process, most errors occur during reconstitution and administration. Dose-error reduction software (DERS) loaded on to infusion pumps incorporates a drug library with predefined upper and lower drug dose limits and infusion rates, which can reduce IV infusion errors. Although this is an important advance for patient safety at the point of care, uptake is still relatively low. This article discuses the challenges and benefits of implementing DERS in clinical practice as experienced by three UK trusts.

The Influence of Observation Errors on Analysis Error and Forecast Skill Investigated with an Observing System Simulation Experiment

NASA Technical Reports Server (NTRS)

Prive, N. C.; Errico, R. M.; Tai, K.-S.

2013-01-01

The Global Modeling and Assimilation Office (GMAO) observing system simulation experiment (OSSE) framework is used to explore the response of analysis error and forecast skill to observation quality. In an OSSE, synthetic observations may be created that have much smaller error than real observations, and precisely quantified error may be applied to these synthetic observations. Three experiments are performed in which synthetic observations with magnitudes of applied observation error that vary from zero to twice the estimated realistic error are ingested into the Goddard Earth Observing System Model (GEOS-5) with Gridpoint Statistical Interpolation (GSI) data assimilation for a one-month period representing July. The analysis increment and observation innovation are strongly impacted by observation error, with much larger variances for increased observation error. The analysis quality is degraded by increased observation error, but the change in root-mean-square error of the analysis state is small relative to the total analysis error. Surprisingly, in the 120 hour forecast increased observation error only yields a slight decline in forecast skill in the extratropics, and no discernable degradation of forecast skill in the tropics.

Psycho-Motor and Error Enabled Simulations: Modeling Vulnerable Skills in the Pre Mastery Phase - Medical Practice Initiative Procedural Skill Decay and Maintenance (MPI-PSD)

DTIC Science & Technology

2016-12-01

repair, bowel anastomosis, central venous catheterization , and bladder catheterization . We performed a multivariate analysis of variance (MANOVA) to...DC, Gould MK. Preventing complications of central venous catheterization . N Engl J Med 2003;348:1123–33. 15. Maithel S, Sierra R, Korndorffer J, et...subclavian-vein catheterization . N Engl J Med. 1994;331(26):1735-1738. 2. Taylor RW, Palagiri AV. Central venous catheter- ization. Crit Care Med. 2007;35(5

The value of bedside shift reporting enhancing nurse surveillance, accountability, and patient safety.

PubMed

Jeffs, Lianne; Acott, Ashley; Simpson, Elisa; Campbell, Heather; Irwin, Terri; Lo, Joyce; Beswick, Susan; Cardoso, Roberta

2013-01-01

A study was undertaken to explore nurses' experiences and perceptions associated with implementation of bedside nurse-to-nurse shift handoff reporting. Interviews were conducted with nurses and analyzed using directed content analysis. Two themes emerged that illustrated the value of bedside shift reporting. These themes included clarifying information and intercepting errors and visualizing patients and prioritizing care. Nurse leaders can leverage study findings in their efforts to embed nurse-to-nurse bedside shift reporting in their respective organizations.

The effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in a multicultural population of internal medicine patients.

PubMed

Karapinar-Carkit, Fatma; Borgsteede, Sander D; Zoer, Jan; Siegert, Carl; van Tulder, Maurits; Egberts, Antoine C G; van den Bemt, Patricia M L A

2010-02-16

Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department. An experimental study is performed at the internal medicine ward of a general teaching hospital in Amsterdam, which serves a multicultural population. In this study the effects of the COACH program is compared with usual care using a pre-post study design. All patients being admitted with at least one prescribed drug intended for chronic use are included in the study unless they meet one of the following exclusion criteria: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home and no possibility to counsel the patient.The intervention consists of medication reconciliation, patient counselling and communication between the hospital and primary care healthcare providers.The following outcomes are measured: the primary outcome readmissions within six months after discharge and the secondary outcomes number of interventions, adherence, patient's attitude towards medicines, patient's satisfaction with medication information, costs, quality of life and finally satisfaction of general practitioners and community pharmacists.Interrupted time series analysis is used for data-analysis of the primary outcome. Descriptive statistics is performed for the secondary outcomes. An economic evaluation is performed according to the intention-to-treat principle. This study will be able to evaluate the clinical and cost impact of a comprehensive program on continuity of care and associated patient safety. Dutch trial register: NTR1519.

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.

PubMed

Anderson, Cheryl I; Nelson, Catherine S; Graham, Corey F; Mosher, Benjamin D; Gohil, Kartik N; Morrison, Chet A; Schneider, Paul D; Kepros, John P

2012-09-01

Performance improvement driven by the review of surgical morbidity and mortality is often limited to critiques of individual cases with a focus on individual errors. Little attention has been given to an analysis of why a decision seemed right at the time or to lower-level root causes. The application of scientific performance improvement has the potential to bring to light deeper levels of understanding of surgical decision-making, care processes, and physician psychology. A comprehensive retrospective chart review of previously discussed morbidity and mortality cases was performed with an attempt to identify areas where we could better understand or influence behavior or systems. We avoided focusing on traditional sources of human error such as lapses of vigilance or memory. An iterative process was used to refine the practical areas for possible intervention. Definitions were then created for the major categories and subcategories. Of a sample of 152 presented cases, the root cause for 96 (63%) patient-related events was identified as uni-factorial in origin, with 51 (34%) cases strictly related to patient disease with no other contributing causes. Fifty-six cases (37%) had multiple causes. The remaining 101 cases (66%) were categorized into two areas where the ability to influence outcomes appeared possible. Technical issues were found in 27 (18%) of these cases and 74 (74%) were related to disorganized care problems. Of the 74 cases identified with disorganized care, 42 (42%) were related to failures in critical thinking, 18 (18%) to undisciplined treatment strategies, 8 (8%) to structural failures, and 6 (6%) were related to failures in situational awareness. On a comprehensive review of cases presented at the morbidity and mortality conference, disorganized care played a large role in the cases presented and may have implications for future curriculum changes. The failure to think critically, to deliver disciplined treatment strategies, to recognize structural failures, and to achieve situational awareness contributed to the morbidities and mortalities. Future research may determine if focused training in these areas improves patient outcomes. Copyright © 2012 Elsevier Inc. All rights reserved.

Reducing patient identification errors related to glucose point-of-care testing.

PubMed

Alreja, Gaurav; Setia, Namrata; Nichols, James; Pantanowitz, Liron

2011-01-01

Patient identification (ID) errors in point-of-care testing (POCT) can cause test results to be transferred to the wrong patient's chart or prevent results from being transmitted and reported. Despite the implementation of patient barcoding and ongoing operator training at our institution, patient ID errors still occur with glucose POCT. The aim of this study was to develop a solution to reduce identification errors with POCT. Glucose POCT was performed by approximately 2,400 clinical operators throughout our health system. Patients are identified by scanning in wristband barcodes or by manual data entry using portable glucose meters. Meters are docked to upload data to a database server which then transmits data to any medical record matching the financial number of the test result. With a new model, meters connect to an interface manager where the patient ID (a nine-digit account number) is checked against patient registration data from admission, discharge, and transfer (ADT) feeds and only matched results are transferred to the patient's electronic medical record. With the new process, the patient ID is checked prior to testing, and testing is prevented until ID errors are resolved. When averaged over a period of a month, ID errors were reduced to 3 errors/month (0.015%) in comparison with 61.5 errors/month (0.319%) before implementing the new meters. Patient ID errors may occur with glucose POCT despite patient barcoding. The verification of patient identification should ideally take place at the bedside before testing occurs so that the errors can be addressed in real time. The introduction of an ADT feed directly to glucose meters reduced patient ID errors in POCT.

Reducing patient identification errors related to glucose point-of-care testing

PubMed Central

Alreja, Gaurav; Setia, Namrata; Nichols, James; Pantanowitz, Liron

2011-01-01

Background: Patient identification (ID) errors in point-of-care testing (POCT) can cause test results to be transferred to the wrong patient's chart or prevent results from being transmitted and reported. Despite the implementation of patient barcoding and ongoing operator training at our institution, patient ID errors still occur with glucose POCT. The aim of this study was to develop a solution to reduce identification errors with POCT. Materials and Methods: Glucose POCT was performed by approximately 2,400 clinical operators throughout our health system. Patients are identified by scanning in wristband barcodes or by manual data entry using portable glucose meters. Meters are docked to upload data to a database server which then transmits data to any medical record matching the financial number of the test result. With a new model, meters connect to an interface manager where the patient ID (a nine-digit account number) is checked against patient registration data from admission, discharge, and transfer (ADT) feeds and only matched results are transferred to the patient's electronic medical record. With the new process, the patient ID is checked prior to testing, and testing is prevented until ID errors are resolved. Results: When averaged over a period of a month, ID errors were reduced to 3 errors/month (0.015%) in comparison with 61.5 errors/month (0.319%) before implementing the new meters. Conclusion: Patient ID errors may occur with glucose POCT despite patient barcoding. The verification of patient identification should ideally take place at the bedside before testing occurs so that the errors can be addressed in real time. The introduction of an ADT feed directly to glucose meters reduced patient ID errors in POCT. PMID:21633490

Improving laboratory data entry quality using Six Sigma.

PubMed

Elbireer, Ali; Le Chasseur, Julie; Jackson, Brooks

2013-01-01

The Uganda Makerere University provides clinical laboratory support to over 70 clients in Uganda. With increased volume, manual data entry errors have steadily increased, prompting laboratory managers to employ the Six Sigma method to evaluate and reduce their problems. The purpose of this paper is to describe how laboratory data entry quality was improved by using Six Sigma. The Six Sigma Quality Improvement (QI) project team followed a sequence of steps, starting with defining project goals, measuring data entry errors to assess current performance, analyzing data and determining data-entry error root causes. Finally the team implemented changes and control measures to address the root causes and to maintain improvements. Establishing the Six Sigma project required considerable resources and maintaining the gains requires additional personnel time and dedicated resources. After initiating the Six Sigma project, there was a 60.5 percent reduction in data entry errors from 423 errors a month (i.e. 4.34 Six Sigma) in the first month, down to an average 166 errors/month (i.e. 4.65 Six Sigma) over 12 months. The team estimated the average cost of identifying and fixing a data entry error to be $16.25 per error. Thus, reducing errors by an average of 257 errors per month over one year has saved the laboratory an estimated $50,115 a year. The Six Sigma QI project provides a replicable framework for Ugandan laboratory staff and other resource-limited organizations to promote quality environment. Laboratory staff can deliver excellent care at a lower cost, by applying QI principles. This innovative QI method of reducing data entry errors in medical laboratories may improve the clinical workflow processes and make cost savings across the health care continuum.

Patient Safety: Moving the Bar in Prison Health Care Standards

PubMed Central

Greifinger, Robert B.; Mellow, Jeff

2010-01-01

Improvements in community health care quality through error reduction have been slow to transfer to correctional settings. We convened a panel of correctional experts, which recommended 60 patient safety standards focusing on such issues as creating safety cultures at organizational, supervisory, and staff levels through changes to policy and training and by ensuring staff competency, reducing medication errors, encouraging the seamless transfer of information between and within practice settings, and developing mechanisms to detect errors or near misses and to shift the emphasis from blaming staff to fixing systems. To our knowledge, this is the first published set of standards focusing on patient safety in prisons, adapted from the emerging literature on quality improvement in the community. PMID:20864714

From unseen to seen: tackling the global burden of uncorrected refractive errors.

PubMed

Durr, Nicholas J; Dave, Shivang R; Lage, Eduardo; Marcos, Susana; Thorn, Frank; Lim, Daryl

2014-07-11

Worldwide, more than one billion people suffer from poor vision because they do not have the eyeglasses they need. Their uncorrected refractive errors are a major cause of global disability and drastically reduce productivity, educational opportunities, and overall quality of life. The problem persists most prevalently in low-resource settings, even though prescription eyeglasses serve as a simple, effective, and largely affordable solution. In this review, we discuss barriers to obtaining, and approaches for providing, refractive eye care. We also highlight emerging technologies that are being developed to increase the accessibility of eye care. Finally, we describe opportunities that exist for engineers to develop new solutions to positively impact the diagnosis and treatment of correctable refractive errors in low-resource settings.

Laboratory testing in primary care: A systematic review of health IT impacts.

PubMed

Maillet, Éric; Paré, Guy; Currie, Leanne M; Raymond, Louis; Ortiz de Guinea, Ana; Trudel, Marie-Claude; Marsan, Josianne

2018-08-01

Laboratory testing in primary care is a fundamental process that supports patient management and care. Any breakdown in the process may alter clinical information gathering and decision-making activities and can lead to medical errors and potential adverse outcomes for patients. Various information technologies are being used in primary care with the goal to support the process, maximize patient benefits and reduce medical errors. However, the overall impact of health information technologies on laboratory testing processes has not been evaluated. To synthesize the positive and negative impacts resulting from the use of health information technology in each phase of the laboratory 'total testing process' in primary care. We conducted a systematic review. Databases including Medline, PubMed, CINAHL, Web of Science and Google Scholar were searched. Studies eligible for inclusion reported empirical data on: 1) the use of a specific IT system, 2) the impacts of the systems to support the laboratory testing process, and were conducted in 3) primary care settings (including ambulatory care and primary care offices). Our final sample consisted of 22 empirical studies which were mapped to a framework that outlines the phases of the laboratory total testing process, focusing on phases where medical errors may occur. Health information technology systems support several phases of the laboratory testing process, from ordering the test to following-up with patients. This is a growing field of research with most studies focusing on the use of information technology during the final phases of the laboratory total testing process. The findings were largely positive. Positive impacts included easier access to test results by primary care providers, reduced turnaround times, and increased prescribed tests based on best practice guidelines. Negative impacts were reported in several studies: paper-based processes employed in parallel to the electronic process increased the potential for medical errors due to clinicians' cognitive overload; systems deemed not reliable or user-friendly hampered clinicians' performance; and organizational issues arose when results tracking relied on the prescribers' memory. The potential of health information technology lies not only in the exchange of health information, but also in knowledge sharing among clinicians. This review has underscored the important role played by cognitive factors, which are critical in the clinician's decision-making, the selection of the most appropriate tests, correct interpretation of the results and efficient interventions. By providing the right information, at the right time to the right clinician, many IT solutions adequately support the laboratory testing process and help primary care clinicians make better decisions. However, several technological and organizational barriers require more attention to fully support the highly fragmented and error-prone process of laboratory testing. Copyright © 2018 Elsevier B.V. All rights reserved.

[Relations between health information systems and patient safety].

PubMed

Nøhr, Christian

2012-11-05

Health information systems have the potential to reduce medical errors, and indeed many studies have shown a significant reduction. However, if the systems are not designed and implemented properly, there is evidence that suggest that new types of errors will arise--i.e., technology-induced errors. Health information systems will need to undergo a more rigorous evaluation. Usability evaluation and simulation test with humans in the loop can help to detect and prevent technology-induced errors before they are deployed in real health-care settings.

[Bibliographic errors in Revista Española de Enfermedades Digestivas. A retrospective study of the year 1995].

PubMed

Acea Nebril, B; Gómez Freijoso, C

1997-03-01

To determine the accuracy of bibliographic citation in Revista Española de Enfermedades Digestivas (REED) and compare it with other Spanish and international journals. We reviewed all 1995 volumes of the REED and randomly selected 100 references from these volumes. Nine citations of non-journal articles were excluded and the remaining 91 citations were carefully scrutinized. Each original article was compared for author's name, title of article, name of journal, volume number, year of publication and pages. Some type of error was detected in 61.6% of the references and on 3 occasions (3.3%) impeded finding to the original article. Errors were found in authors (37.3%); article title (16.4%), pages (6.6%), journal title (4.4%), volume (2.2%) and year (1%). A single error was found in 42 citations, 2 were found in 13 and 3 were found in 1. REED's rate of error in references is comparable to the rates of other spanish and international journals. Authors should exercise more care in preparing bibliographies and should invest more effort in verification of quoted references.

Compounded Pain Creams and Adverse Effects; Postanesthesia Care Unit ADC Selection Error; Docetaxel Product Has Unusual Concentration; Tragic Vaccine Diluent Mix-ups.

PubMed

Cohen, Michael R; Smetzer, Judy L

2015-01-01

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Does bad inference drive out good?

PubMed

Marozzi, Marco

2015-07-01

The (mis)use of statistics in practice is widely debated, and a field where the debate is particularly active is medicine. Many scholars emphasize that a large proportion of published medical research contains statistical errors. It has been noted that top class journals like Nature Medicine and The New England Journal of Medicine publish a considerable proportion of papers that contain statistical errors and poorly document the application of statistical methods. This paper joins the debate on the (mis)use of statistics in the medical literature. Even though the validation process of a statistical result may be quite elusive, a careful assessment of underlying assumptions is central in medicine as well as in other fields where a statistical method is applied. Unfortunately, a careful assessment of underlying assumptions is missing in many papers, including those published in top class journals. In this paper, it is shown that nonparametric methods are good alternatives to parametric methods when the assumptions for the latter ones are not satisfied. A key point to solve the problem of the misuse of statistics in the medical literature is that all journals have their own statisticians to review the statistical method/analysis section in each submitted paper. © 2015 Wiley Publishing Asia Pty Ltd.

Preliminary design of the redundant software experiment

NASA Technical Reports Server (NTRS)

Campbell, Roy; Deimel, Lionel; Eckhardt, Dave, Jr.; Kelly, John; Knight, John; Lauterbach, Linda; Lee, Larry; Mcallister, Dave; Mchugh, John

1985-01-01

The goal of the present experiment is to characterize the fault distributions of highly reliable software replicates, constructed using techniques and environments which are similar to those used in comtemporary industrial software facilities. The fault distributions and their effect on the reliability of fault tolerant configurations of the software will be determined through extensive life testing of the replicates against carefully constructed randomly generated test data. Each detected error will be carefully analyzed to provide insight in to their nature and cause. A direct objective is to develop techniques for reducing the intensity of coincident errors, thus increasing the reliability gain which can be achieved with fault tolerance. Data on the reliability gains realized, and the cost of the fault tolerant configurations can be used to design a companion experiment to determine the cost effectiveness of the fault tolerant strategy. Finally, the data and analysis produced by this experiment will be valuable to the software engineering community as a whole because it will provide a useful insight into the nature and cause of hard to find, subtle faults which escape standard software engineering validation techniques and thus persist far into the software life cycle.

[Optimization of blood gas analysis in intensive care units : Reduction of preanalytical errors and improvement of workflow].

PubMed

Kieninger, M; Zech, N; Mulzer, Y; Bele, S; Seemann, M; Künzig, H; Schneiker, A; Gruber, M

2015-05-01

Point of care testing with blood gas analysis (BGA) is an important factor for intensive care medicine. Continuous efforts to optimize workflow, improve safety for the staff and avoid preanalytical mistakes are important and should reflect quality management standards. In a prospective observational study it was investigated whether the implementation of a new system for BGA using labeled syringes and automated processing of the specimens leads to improvements compared to the previously used procedure. In a 4-week test period the time until receiving the final results of the BGA with the standard method used in the clinical routine (control group) was compared to the results in a second 4-week test period using the new labeled syringes and automated processing of the specimens (intervention group). In addition, preanalytical mistakes with both systems were checked during routine daily use. Finally, it was investigated whether a delay of 10 min between taking and analyzing the blood samples alters the results of the BGA. Preanalytical errors were frequently observed in the control group where non-deaerated samples were recorded in 87.3 % but in the intervention group almost all samples (98.9 %) were correctly deaerated. Insufficient homogenization due to omission of manual pivoting was seen in 83.2 % in the control group and in 89.9 % in the intervention group; however, in the intervention group the samples were homogenized automatically during the further analytical process. Although a survey among the staff revealed a high acceptance of the new system and a subjective improvement of workflow, a measurable gain in time after conversion to the new procedure could not be seen. The mean time needed for a complete analysis process until receiving the final results was 244 s in the intervention group and 201 s in the control group. A 10-min delay between taking and analyzing the blood samples led to a significant and clinically relevant elevation of the values for partial pressure of oxygen (pO2) in both groups compared to the results when analyzing the samples immediately (118.4 vs. 148.6 mmHg in the control group and 115.3 vs. 123.7 mmHg in the intervention group). When using standard syringes the partial pressure of carbon dioxide (pCO2) was significantly lower (40.5 vs. 38.3 mmHg) whereas no alterations were seen when using the labeled syringes. The implementation of a new BGA system with labeled syringes and automated processing of the specimens was possible without any difficulties under daily clinical routine conditions in this 10-bed intensive care unit (ICU). A gain of time could not be measured but a reduction in preanalytical errors using the labeled syringes with automated processing was found. Delayed analysis of blood samples can lead to significant changes in pO2 and pCO2 depending on the type of syringe used.

Model-based virtual VSB mask writer verification for efficient mask error checking and optimization prior to MDP

NASA Astrophysics Data System (ADS)

Pack, Robert C.; Standiford, Keith; Lukanc, Todd; Ning, Guo Xiang; Verma, Piyush; Batarseh, Fadi; Chua, Gek Soon; Fujimura, Akira; Pang, Linyong

2014-10-01

A methodology is described wherein a calibrated model-based `Virtual' Variable Shaped Beam (VSB) mask writer process simulator is used to accurately verify complex Optical Proximity Correction (OPC) and Inverse Lithography Technology (ILT) mask designs prior to Mask Data Preparation (MDP) and mask fabrication. This type of verification addresses physical effects which occur in mask writing that may impact lithographic printing fidelity and variability. The work described here is motivated by requirements for extreme accuracy and control of variations for today's most demanding IC products. These extreme demands necessitate careful and detailed analysis of all potential sources of uncompensated error or variation and extreme control of these at each stage of the integrated OPC/ MDP/ Mask/ silicon lithography flow. The important potential sources of variation we focus on here originate on the basis of VSB mask writer physics and other errors inherent in the mask writing process. The deposited electron beam dose distribution may be examined in a manner similar to optical lithography aerial image analysis and image edge log-slope analysis. This approach enables one to catch, grade, and mitigate problems early and thus reduce the likelihood for costly long-loop iterations between OPC, MDP, and wafer fabrication flows. It moreover describes how to detect regions of a layout or mask where hotspots may occur or where the robustness to intrinsic variations may be improved by modification to the OPC, choice of mask technology, or by judicious design of VSB shots and dose assignment.

A nationwide descriptive study of obstetric claims for compensation in Norway.

PubMed

Andreasen, Stine; Backe, Bjørn; Jørstad, Rolf Gunnar; Oian, Pål

2012-10-01

To describe causes of substandard care in obstetric compensation claims. A nationwide descriptive study in Norway. All obstetric patients who believed themselves inflicted with injuries by the Health Service and applying for compensation. Data were collected from 871 claims to The Norwegian System of Compensation to Patients during 1994-2008, of which 278 were awarded compensation. Type of injury and cause of substandard care. Of 871 cases, 278 (31.9%) resulted in compensation. Of those, asphyxia was the most common type of injury to the child (83.4%). Anal sphincter tear (29.9%) and infection (23.0%) were the most common types of injury to the mother. Human error, both by midwives (37.1% of all cases given compensation) and obstetricians (51.2%), was an important contributing factor in inadequate obstetric care. Neglecting signs of fetal distress (28.1%), more competent health workers not being called when appropriate (26.3%) and inadequate fetal monitoring (17.3%) were often observed. System errors such as time conflicts, neglecting written guidelines and poor organization of the department were infrequent causes of injury (8.3%). Fetal asphyxia is the most common reason for compensation, resulting in large financial expenses to society. Human error contributes to inadequate health care in 92% of obstetric compensation claims, although underlying system errors may also be present. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology.

The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper.

PubMed

Johnstone, Megan-Jane; Kanitsaki, Olga

2006-03-01

Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of 'nursing error', the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of 'nursing error' fits with the new 'system approach' to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is 'right' for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

Impact of Pharmacists in a Community-Based Home Care Service: A Pilot Program.

PubMed

Walus, Ashley N; Woloschuk, Donna M M

2017-01-01

Historically, pharmacists have not been included on home care teams, despite the fact that home care patients frequently experience medication errors. Literature describing Canadian models of pharmacy practice in home care settings is limited. The optimal service delivery model and distribution of clinical activities for home care pharmacists remain unclear. The primary objective was to describe the impact of a pharmacist based at a community home care office and providing home visits, group education, and telephone consultations. The secondary objective was to determine the utility of acute care clinical pharmacy key performance indicators (cpKPIs) in guiding home care pharmacy services, in the absence of validated cpKPIs for ambulatory care. The Winnipeg Regional Health Authority hired a pharmacist to develop and implement the pilot program from May 2015 to July 2016. A referral form, consisting of consultation criteria used in primary care practices, was developed. The pharmacist also reviewed all patient intakes and all patients waiting in acute care facilities for initiation of home care services, with the goal of addressing issues before admission to the Home Care Program. A password-protected database was built for data collection and analysis, and the data are presented in aggregate. A total of 197 referrals, involving 184 patients, were received during the pilot program; of these, 62 were excluded from analysis. The majority of referrals (95 [70.4%]) were for targeted medication reviews, and 271 drug therapy problems were identified. Acceptance rates for the pharmacist's recommendations were 90.2% (74 of 82 recommendations) among home care staff and 47.0% (55 of 117 recommendations) among prescribers and patients. On average, 1.5 cpKPIs were identified for each referral. The pilot program demonstrated a need for enhanced access to clinical pharmacy services for home care patients, although the best model of service provision remains unclear. More research is warranted to determine the optimal pharmacy service for home care patients and the most appropriate cpKPIs to measure its effects.

One Size Does Not Fit All: Human Failure Event Decomposition and Task Analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ronald Laurids Boring, PhD

2014-09-01

In the probabilistic safety assessments (PSAs) used in the nuclear industry, human failure events (HFEs) are determined as a subset of hardware failures, namely those hardware failures that could be triggered or exacerbated by human action or inaction. This approach is top-down, starting with hardware faults and deducing human contributions to those faults. Elsewhere, more traditionally human factors driven approaches would tend to look at opportunities for human errors first in a task analysis and then identify which of those errors is risk significant. The intersection of top-down and bottom-up approaches to defining HFEs has not been carefully studied. Ideally,more » both approaches should arrive at the same set of HFEs. This question remains central as human reliability analysis (HRA) methods are generalized to new domains like oil and gas. The HFEs used in nuclear PSAs tend to be top-down—defined as a subset of the PSA—whereas the HFEs used in petroleum quantitative risk assessments (QRAs) are more likely to be bottom-up—derived from a task analysis conducted by human factors experts. The marriage of these approaches is necessary in order to ensure that HRA methods developed for top-down HFEs are also sufficient for bottom-up applications. In this paper, I first review top-down and bottom-up approaches for defining HFEs and then present a seven-step guideline to ensure a task analysis completed as part of human error identification decomposes to a level suitable for use as HFEs. This guideline illustrates an effective way to bridge the bottom-up approach with top-down requirements.« less

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care.

PubMed

Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M; Wensing, Michel; Esmail, Aneez

2015-09-01

Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. To outline a research agenda for patient safety improvement in primary care in Europe and beyond. The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care

PubMed Central

Verstappen, Wim; Gaal, Sander; Bowie, Paul; Parker, Diane; Lainer, Miriam; Valderas, Jose M.; Wensing, Michel; Esmail, Aneez

2015-01-01

ABSTRACT Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond. Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement. PMID:26339841

Assessing the accuracy of the International Classification of Diseases codes to identify abusive head trauma: a feasibility study.

PubMed

Berger, Rachel P; Parks, Sharyn; Fromkin, Janet; Rubin, Pamela; Pecora, Peter J

2015-04-01

To assess the accuracy of an International Classification of Diseases (ICD) code-based operational case definition for abusive head trauma (AHT). Subjects were children <5 years of age evaluated for AHT by a hospital-based Child Protection Team (CPT) at a tertiary care paediatric hospital with a completely electronic medical record (EMR) system. Subjects were designated as non-AHT traumatic brain injury (TBI) or AHT based on whether the CPT determined that the injuries were due to AHT. The sensitivity and specificity of the ICD-based definition were calculated. There were 223 children evaluated for AHT: 117 AHT and 106 non-AHT TBI. The sensitivity and specificity of the ICD-based operational case definition were 92% (95% CI 85.8 to 96.2) and 96% (95% CI 92.3 to 99.7), respectively. All errors in sensitivity and three of the four specificity errors were due to coder error; one specificity error was a physician error. In a paediatric tertiary care hospital with an EMR system, the accuracy of an ICD-based case definition for AHT was high. Additional studies are needed to assess the accuracy of this definition in all types of hospitals in which children with AHT are cared for. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

A Model of Self-Monitoring Blood Glucose Measurement Error.

PubMed

Vettoretti, Martina; Facchinetti, Andrea; Sparacino, Giovanni; Cobelli, Claudio

2017-07-01

A reliable model of the probability density function (PDF) of self-monitoring of blood glucose (SMBG) measurement error would be important for several applications in diabetes, like testing in silico insulin therapies. In the literature, the PDF of SMBG error is usually described by a Gaussian function, whose symmetry and simplicity are unable to properly describe the variability of experimental data. Here, we propose a new methodology to derive more realistic models of SMBG error PDF. The blood glucose range is divided into zones where error (absolute or relative) presents a constant standard deviation (SD). In each zone, a suitable PDF model is fitted by maximum-likelihood to experimental data. Model validation is performed by goodness-of-fit tests. The method is tested on two databases collected by the One Touch Ultra 2 (OTU2; Lifescan Inc, Milpitas, CA) and the Bayer Contour Next USB (BCN; Bayer HealthCare LLC, Diabetes Care, Whippany, NJ). In both cases, skew-normal and exponential models are used to describe the distribution of errors and outliers, respectively. Two zones were identified: zone 1 with constant SD absolute error; zone 2 with constant SD relative error. Goodness-of-fit tests confirmed that identified PDF models are valid and superior to Gaussian models used so far in the literature. The proposed methodology allows to derive realistic models of SMBG error PDF. These models can be used in several investigations of present interest in the scientific community, for example, to perform in silico clinical trials to compare SMBG-based with nonadjunctive CGM-based insulin treatments.

Factor structure of the geriatric care environment scale.

PubMed

Kim, Hongsoo; Capezuti, Elizabeth; Boltz, Marie; Fairchild, Susan; Fulmer, Terry; Mezey, Mathy

2007-01-01

Older adults comprise approximately 60% of all adult, nonobstetric hospital admissions. Nurses Improving Care for Health System Elders (NICHE) is a national program aimed at system improvement to achieve patient-centered care for older adults. The NICHE hospitals use the Geriatric Institutional Assessment Profile (GIAP) to assess their institutional readiness to provide quality care to older adults and to document improvement in geriatric care delivery. To explore the factorial structure of the 28-item Geriatric Care Environment Scale (GCES) of the GIAP, test its validity with a sample of staff registered nurses (RNs), and evaluate its invariance across 4 groups of RNs who worked at 4 different types of hospitals. Staff RNs (N = 9,400) at 71 acute hospitals, who responded to the GIAP from 1999 to 2004, were split randomly into 2 groups for cross-validation. A 3-step data analysis was completed. The a priori factor structure was developed using exploratory factor analysis. The obtained factor model was validated, and its invariance by types of hospitals was examined by confirmatory factor analyses. The GCES is internally consistent (Cronbach's alpha = .93) and accounts for approximately 55% of the total variance. The 4 factors extracted from the exploratory factor analysis are Aging-Sensitive Care Delivery, Resource Availability, Institutional Values Regarding Older Adults and Staff, and Capacity for Collaboration. The 4-factor structured model is validated in a half-randomly selected sample (normed fit index [NFI] = .931, nonnormed fit index [NNFI] = .933, comparative fit index [CFI] = .939, root-mean-square error of approximation [RMSEA] = .058) and does not vary significantly across the 4 groups of RNs who worked at the 4 different types of hospitals (NFI = .969, NNFI = .975, CFI = .976, RMSEA = .027). The GCES is a reliable measure of RN perception of how care provided to older adults reflects age-sensitive principles and the organizational practice environment that supports or hinders care delivery.

The influence of NO and ClO variations at twilight on the interpretation of solar occultation measurements

NASA Technical Reports Server (NTRS)

Boughner, R.; Larsen, J. C.; Natarajan, M.

1980-01-01

The influence of short lived photochemically produced species on solar occultation measurements of ClO and NO was examined. Time varying altitude profiles of ClO and NO were calculated with a time dependent photochemical model to simulate the distribution of these species during a solar occultation measurement. These distributions were subsequently used to calculate simulated radiances for various tangent paths from which mixing ratios were inferred with a conventional technique that assumes spherical symmetry. These results show that neglecting the variation of ClO in the retrieval process produces less than a 10 percent error between the true and inverted profile for both sunrise and sunset above 18 km. For NO, errors are less than 10 percent for tangent altitudes above about 35 km for sunrise and sunset; at lower altitudes, the error increases, approaching 100 percent at altitudes near 25 km. the results also show that average inhomogeneity factors, which measure the concentration variation along the tangent path and which can be calculated from a photochemical model, can indicate which species require more careful data analysis.

[Knowledge of nurses about medication doses at pediatric urgency departament].

PubMed

Guerrero-Márquez, Gloria; Martínez-Serrano, Ana; Míguez-Navarro, Concepción; López-Mirón, Juan Antonio; Espartosa-Larrayad, Marta

2016-01-01

Errors in drug administration are the second cause of errors in hospitalized patients. Children are a high risk group. Besides, pressure in care interventions at emergency department leads to increase incidence errors. Determining nurses' knowledge about the most common drug doses at pediatric urgency department. Descriptive transversal study. We collected data from nurses of 14 pediatric emergency departments of Madrid. With an "ad hoc" questionnaire we collected the following data during five days in January of 2014: demographic, knowledge of responsibility in administration and doses of drugs. Global descriptive analysis was made and it was stratified by hospital and work experience. The answer rate was 114 (34.9%). Only 80 (70.8%) of nurses confirm doses before their administration; 20 (18.6%) think that a wrong prescription that they administer is not their responsibility. There is a high knowledge in the group with more than five years of work experience, except for sedative-analgesic drugs (p<0.05). The average score obtained was 3.8 of 10 (1.99). Nurses' knowledge about drug doses is low. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

Commentary: Reducing diagnostic errors: another role for checklists?

PubMed

Winters, Bradford D; Aswani, Monica S; Pronovost, Peter J

2011-03-01

Diagnostic errors are a widespread problem, although the true magnitude is unknown because they cannot currently be measured validly. These errors have received relatively little attention despite alarming estimates of associated harm and death. One promising intervention to reduce preventable harm is the checklist. This intervention has proven successful in aviation, in which situations are linear and deterministic (one alarm goes off and a checklist guides the flight crew to evaluate the cause). In health care, problems are multifactorial and complex. A checklist has been used to reduce central-line-associated bloodstream infections in intensive care units. Nevertheless, this checklist was incorporated in a culture-based safety program that engaged and changed behaviors and used robust measurement of infections to evaluate progress. In this issue, Ely and colleagues describe how three checklists could reduce the cognitive biases and mental shortcuts that underlie diagnostic errors, but point out that these tools still need to be tested. To be effective, they must reduce diagnostic errors (efficacy) and be routinely used in practice (effectiveness). Such tools must intuitively support how the human brain works, and under time pressures, clinicians rarely think in conditional probabilities when making decisions. To move forward, it is necessary to accurately measure diagnostic errors (which could come from mapping out the diagnostic process as the medication process has done and measuring errors at each step) and pilot test interventions such as these checklists to determine whether they work.

Prevalence and types of preanalytical error in hematology laboratory of a tertiary care hospital in South India.

PubMed

Arul, Pitchaikaran; Pushparaj, Magesh; Pandian, Kanmani; Chennimalai, Lingasamy; Rajendran, Karthika; Selvaraj, Eniya; Masilamani, Suresh

2018-01-01

An important component of laboratory medicine is preanalytical phase. Since laboratory report plays a major role in patient management, more importance should be given to the quality of laboratory tests. The present study was undertaken to find the prevalence and types of preanalytical errors at a tertiary care hospital in South India. In this cross-sectional study, a total of 118,732 samples ([62,474 outpatient department [OPD] and 56,258 inpatient department [IPD]) were received in hematology laboratory. These samples were analyzed for preanalytical errors such as misidentification, incorrect vials, inadequate samples, clotted samples, diluted samples, and hemolyzed samples. The overall prevalence of preanalytical errors found was 513 samples, which is 0.43% of the total number of samples received. The most common preanalytical error observed was inadequate samples followed by clotted samples. Overall frequencies (both OPD and IPD) of preanalytical errors such as misidentification, incorrect vials, inadequate samples, clotted samples, diluted samples, and hemolyzed samples were 0.02%, 0.05%, 0.2%, 0.12%, 0.02%, and 0.03%, respectively. The present study concluded that incorrect phlebotomy techniques due to lack of awareness is the main reason for preanalytical errors. This can be avoided by proper communication and coordination between laboratory and wards, proper training and continuing medical education programs for laboratory and paramedical staffs, and knowledge of the intervening factors that can influence laboratory results.

Measuring diagnoses: ICD code accuracy.

PubMed

O'Malley, Kimberly J; Cook, Karon F; Price, Matt D; Wildes, Kimberly Raiford; Hurdle, John F; Ashton, Carol M

2005-10-01

To examine potential sources of errors at each step of the described inpatient International Classification of Diseases (ICD) coding process. The use of disease codes from the ICD has expanded from classifying morbidity and mortality information for statistical purposes to diverse sets of applications in research, health care policy, and health care finance. By describing a brief history of ICD coding, detailing the process for assigning codes, identifying where errors can be introduced into the process, and reviewing methods for examining code accuracy, we help code users more systematically evaluate code accuracy for their particular applications. We summarize the inpatient ICD diagnostic coding process from patient admission to diagnostic code assignment. We examine potential sources of errors at each step and offer code users a tool for systematically evaluating code accuracy. Main error sources along the "patient trajectory" include amount and quality of information at admission, communication among patients and providers, the clinician's knowledge and experience with the illness, and the clinician's attention to detail. Main error sources along the "paper trail" include variance in the electronic and written records, coder training and experience, facility quality-control efforts, and unintentional and intentional coder errors, such as misspecification, unbundling, and upcoding. By clearly specifying the code assignment process and heightening their awareness of potential error sources, code users can better evaluate the applicability and limitations of codes for their particular situations. ICD codes can then be used in the most appropriate ways.

Error reporting in transfusion medicine at a tertiary care centre: a patient safety initiative.

PubMed

Elhence, Priti; Shenoy, Veena; Verma, Anupam; Sachan, Deepti

2012-11-01

Errors in the transfusion process can compromise patient safety. A study was undertaken at our center to identify the errors in the transfusion process and their causes in order to reduce their occurrence by corrective and preventive actions. All near miss, no harm events and adverse events reported in the 'transfusion process' during 1 year study period were recorded, classified and analyzed at a tertiary care teaching hospital in North India. In total, 285 transfusion related events were reported during the study period. Of these, there were four adverse (1.5%), 10 no harm (3.5%) and 271 (95%) near miss events. Incorrect blood component transfusion rate was 1 in 6031 component units. ABO incompatible transfusion rate was one in 15,077 component units issued or one in 26,200 PRBC units issued and acute hemolytic transfusion reaction due to ABO incompatible transfusion was 1 in 60,309 component units issued. Fifty-three percent of the antecedent near miss events were bedside events. Patient sample handling errors were the single largest category of errors (n=94, 33%) followed by errors in labeling and blood component handling and storage in user areas. The actual and near miss event data obtained through this initiative provided us with clear evidence about latent defects and critical points in the transfusion process so that corrective and preventive actions could be taken to reduce errors and improve transfusion safety.

Afraid in the hospital: parental concern for errors during a child's hospitalization.

PubMed

Tarini, Beth A; Lozano, Paula; Christakis, Dimitri A

2009-11-01

(1) To determine the proportion of parents concerned about medical errors during a child's hospitalization; and (2) the association between this concern and parental self-efficacy with physician interactions. Cross-sectional survey. Tertiary care children's hospital. Parents of children admitted to the general medical service. Parental concern about medical errors. : Parents were asked their agreement with the statement "When my child is in the hospital I feel that I have to watch over the care that he/she is receiving to make sure that mistakes aren't made." We used multivariate logistic regression to examine the association between parents' self-efficacy with physician interactions and the need "to watch over a child's care," adjusting for parent and child demographics, English proficiency, past hospitalization, and social desirability bias. Of 278 eligible parents, 130 completed surveys and 63% reported the need to watch over their child's care to ensure that mistakes were not made. Parents with greater self-efficacy with physician interactions were less likely to report this need (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72-0.92). All parents who were "very uncomfortable" communicating with doctors in English reported the need to watch over their child's care to prevent mistakes. Nearly two-thirds of surveyed parents felt the need to watch over their child's hospital care to prevent mistakes. Parents with greater self-efficacy with physician interactions were less likely to report the need to watch over their child's care while parents with lower English proficiency were more likely to report this need.

Educational background of nurses and their perceptions of the quality and safety of patient care.

PubMed

Swart, Reece P; Pretorius, Ronel; Klopper, Hester

2015-04-30

International health systems research confirms the critical role that nurses play in ensuring the delivery of high quality patient care and subsequent patient safety. It is therefore important that the education of nurses should prepare them for the provision of safe care of a high quality. The South African healthcare system is made up of public and private hospitals that employ various categories of nurses. The perceptions of the various categories of nurses with reference to quality of care and patient safety are unknown in South Africa (SA). To determine the relationship between the educational background of nurses and their perceptions of quality of care and patient safety in private surgical units in SA. A descriptive correlational design was used. A questionnaire was used for data collection, after which hierarchical linear modelling was utilised to determine the relationships amongst the variables. Both the registered- and enrolled nurses seemed satisfied with the quality of care and patient safety in the units were they work. Enrolled nurses (ENs) indicated that current efforts to prevent errors are adequate, whilst the registered nurses (RNs) obtained high scores in reporting incidents in surgical wards. From the results it was evident that perceptions of RNs and ENs related to the quality of care and patient safety differed. There seemed to be a statistically-significant difference between RNs and ENs perceptions of the prevention of errors in the unit, losing patient information between shifts and patient incidents related to medication errors, pressure ulcers and falls with injury.

The effect of prenatal drug exposure and caregiving context on children's performance on a task of sustained visual attention.

PubMed

Ackerman, John P; Llorente, Antolin M; Black, Maureen M; Ackerman, Claire S; Mayes, Lacy A; Nair, Prasanna

2008-12-01

Three groups of children from low-income, urban environments were examined to determine the effects of prenatal drug exposure (PDE) and caregiving environment on sustained visual attention (SVA) at 7 years of age. Drug-exposed children remaining in maternal care (n = 43), drug-exposed children placed in nonmaternal care (n = 45), and community comparison (CC) children (n = 56) were administered a battery of neurocognitive tests, including the Conners' Continuous Performance Test (CPT). PDE children remaining in maternal care displayed more omission errors than CC children. PDE children in nonmaternal care had intermediate scores that did not differ significantly from PDE children in maternal care or CC children. There were no group differences with respect to commission errors or reaction time. CPT errors of omission and commission were significantly correlated with parent-reported attention problems and academic achievement scores. PDE in the context of care provided by a maternal caregiver with persistent drug use patterns may contribute to problems in children's SVA at school-age. As parental drug abuse can interfere with the provision of early care, children raised in a drug-using context may be highly vulnerable to problems with self-regulation, including sustained attention. SVA problems may contribute to subsequent academic and behavioral problems as demands for concentration and sustained effort increase throughout childhood. Children who have been prenatally exposed to drugs or raised in a drug-using household may benefit from early intervention services to avoid problems in SVA that may interfere with subsequent neurocognitive functioning and academic performance.

Training in Trauma Surgery

PubMed Central

Reilly, Patrick M.; Schwab, C William; Haut, Elliott R.; Gracias, Vicente H.; Dabrowski, G Paul; Gupta, Rajan; Pryor, John P.; Kauder, Donald R.

2003-01-01

Objective: To describe outcomes from a clinical trauma surgical education program that places the board-eligible/board-certified fellow in the role of the attending surgeon (fellow-in-exception [FIE]) during the latter half of a 2-year trauma/surgical critical care fellowship. Summary Background Data: National discussions have begun to explore the question of optimal methods for postresidency training in surgery. Few objective studies are available to evaluate current training models. Methods: We analyzed provider-specific data from both our trauma registry and performance improvement (PI) databases. In addition, we performed TRISS analysis when all data were available. Registry and PI data were analyzed as 2 groups (faculty trauma surgeons and FIEs) to determine experience, safety, and trends in errors. We also surveyed graduate fellows using a questionnaire that evaluated perceptions of training and experience on a 6-point Likert scale. Results: During a 4-year period 7,769 trauma patients were evaluated, of which 46.3% met criteria to be submitted to the PA Trauma Outcome Study (PTOS, ie, more severe injury). The faculty group saw 5,885 patients (2,720 PTOS); the FIE group saw 1,884 patients (879 PTOS). The groups were similar in respect to mechanism of injury (74% blunt; 26% penetrating both groups) and injury severity (mean ISS faculty 10.0; FIEs 9.5). When indexed to patient contacts, FIEs did more operations than the faculty group (28.4% versus 25.6%; P < 0.05). Death rates were similar between groups (faculty 10.5%; FIEs 10.0%). Analysis of deaths using PI and TRISS data failed to demonstrate differences between the groups. Analysis of provider-specific errors demonstrated a slightly higher rate for FIEs when compared with faculty when indexed to PTOS cases (4.1% versus 2.1%; P < 0.01). For both groups, errors in management were more common than errors in technique. Twenty-one (91%) of twenty-three surveys were returned. Fellows’ feelings of preparedness to manage complex trauma patients improved during the fellowship (mean 3.2 prior to fellowship versus 4.5 after first year versus 5.8 after FIE year; P < 0.05 by ANOVA). Eighty percent rated the FIE educational experience “great -5” or “exceptional– 6.” Eighty-five percent consider the current structure of the fellowship (with FIE year) as ideal. Ninety percent would repeat the fellowship. Conclusion: The educational experience and training improvement offered by the inclusion of a FIE period during a trauma fellowship is exceptional. Patient outcomes are unchanged. The potential for an increased error rate is present during this period of clinical autonomy and must be addressed when designing the methods of supervision of care to assure concurrent senior staff review. PMID:14530731

The epidemiology of malpractice claims in primary care: a systematic review

PubMed Central

Wallace, E; Lowry, J; Smith, S M; Fahey, T

2013-01-01

Objectives The aim of this systematic review was to examine the epidemiology of malpractice claims in primary care. Design A computerised systematic literature search was conducted. Studies were included if they reported original data (≥10 cases) pertinent to malpractice claims, were based in primary care and were published in the English language. Data were synthesised using a narrative approach. Setting Primary care. Participants Malpractice claimants. Primary outcome Malpractice claim (defined as a written demand for compensation for medical injury). We recorded: medical misadventure cited in claims, missed/delayed diagnoses cited in claims, outcome of claims, prevalence of claims and compensation awarded to claimants. Results Of the 7152 articles retrieved by electronic search, a total of 34 studies met the inclusion criteria and were included in the narrative analysis. Twenty-eight studies presented data from medical indemnity malpractice claims databases and six studies presented survey data. Fifteen studies were based in the USA, nine in the UK, seven in Australia, one in Canada and two in France. The commonest medical misadventure resulting in claims was failure to or delay in diagnosis, which represented 26–63% of all claims across included studies. Common missed or delayed diagnoses included cancer and myocardial infarction in adults and meningitis in children. Medication error represented the second commonest domain representing 5.6–20% of all claims across included studies. The prevalence of malpractice claims in primary care varied across countries. In the USA and Australia when compared with other clinical disciplines, general practice ranked in the top five specialties accounting for the most claims, representing 7.6–20% of all claims. However, the majority of claims were successfully defended. Conclusions This review of malpractice claims in primary care highlights diagnosis and medication error as areas to be prioritised in developing educational strategies and risk management systems. PMID:23869100

Complex clinical reasoning in the critical care unit - difficulties, pitfalls and adaptive strategies.

PubMed

Shaw, M; Singh, S

2015-04-01

Diagnostic error has implications for both clinical outcome and resource utilisation, and may often be traced to impaired data gathering, processing or synthesis because of the influence of cognitive bias. Factors inherent to the intensive/acute care environment afford multiple additional opportunities for such errors to occur. This article illustrates many of these with reference to a case encountered on our intensive care unit. Strategies to improve completeness of data gathering, processing and synthesis in the acute care environment are critically appraised in the context of early detection and amelioration of cognitive bias. These include reflection, targeted simulation training and the integration of social media and IT based aids in complex diagnostic processes. A framework which can be quickly and easily employed in a variety of clinical environments is then presented. © 2015 John Wiley & Sons Ltd.

Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit.

PubMed

Shulman, Rob; Singer, Mervyn; Goldstone, John; Bellingan, Geoff

2005-10-05

The study aimed to compare the impact of computerised physician order entry (CPOE) without decision support with hand-written prescribing (HWP) on the frequency, type and outcome of medication errors (MEs) in the intensive care unit. Details of MEs were collected before, and at several time points after, the change from HWP to CPOE. The study was conducted in a London teaching hospital's 22-bedded general ICU. The sampling periods were 28 weeks before and 2, 10, 25 and 37 weeks after introduction of CPOE. The unit pharmacist prospectively recorded details of MEs and the total number of drugs prescribed daily during the data collection periods, during the course of his normal chart review. The total proportion of MEs was significantly lower with CPOE (117 errors from 2429 prescriptions, 4.8%) than with HWP (69 errors from 1036 prescriptions, 6.7%) (p < 0.04). The proportion of errors reduced with time following the introduction of CPOE (p < 0.001). Two errors with CPOE led to patient harm requiring an increase in length of stay and, if administered, three prescriptions with CPOE could potentially have led to permanent harm or death. Differences in the types of error between systems were noted. There was a reduction in major/moderate patient outcomes with CPOE when non-intercepted and intercepted errors were combined (p = 0.01). The mean baseline APACHE II score did not differ significantly between the HWP and the CPOE periods (19.4 versus 20.0, respectively, p = 0.71). Introduction of CPOE was associated with a reduction in the proportion of MEs and an improvement in the overall patient outcome score (if intercepted errors were included). Moderate and major errors, however, remain a significant concern with CPOE.

In-hospital fellow coverage reduces communication errors in the surgical intensive care unit.

PubMed

Williams, Mallory; Alban, Rodrigo F; Hardy, James P; Oxman, David A; Garcia, Edward R; Hevelone, Nathanael; Frendl, Gyorgy; Rogers, Selwyn O

2014-06-01

Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events. A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods. Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (P<.0001). Residents communicated 89% of events during IHFC vs 51% of events during HC (P<.001). Communication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, P<.001). Junior residents communicated 66% of events (94% IHFC vs 52% HC, P<.001). Communication errors were lower in all ICUs during IHFC (P<.001). IHFC reduced communication errors. Copyright © 2014 Elsevier Inc. All rights reserved.