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At least 451 records · Page 25Linked to original sources
PubMed1994

The use of failure mode effect and criticality analysis in a medication error subcommittee.

Failure Mode Effect and Criticality Analysis (FMECA) is the systematic assessment of a process or product that enables one to determine the location and mechanism of potential failures. It has been used by engineers, particularly in the aerospace industry, to identify and prioritize potential failures during product development when there is a lack of data but an abundance of expertise. The Institute for Safe Medication Practices has recommended its use in analyzing the medication administration process in hospitals and in drug product development in the pharamceutical industry. A medication error subcommittee adopted and modified FMECA to identify and prioritize significant failure modes in its specific medication administration process. Based on this analysis, the subcommittee implemented solutions to four of the five highest ranked failure modes. FMECA provided a method for a multidisciplinary group to address the most important medication error concerns based upon the expertise of the group members. It also facilitated consensus building in a group with varied perceptions.

Accident Prevention↗
PubMed2005

[Frequency, relevance, causes of and strategies for prevention of medication errors].

Drug therapy has led to major advances in medicine. The beneficial effects of drug therapy are coupled with the inevitable risk of adverse drug reactions especially in elderly patients. Many adverse drug reactions are preventable. The electronic health card that will be introduced in Germany starting in 2006 is designed to support electronic decision support to prevent medication errors. Studies have demonstrated that CPOES can reduce medication errors by 80%. The necessary steps to improve medication safety in Germany are outlined and discussed.

Aged↗
PubMedDate not supplied

[Medico-legal assessment of selected cases of perinatal complications resulting in death of the woman during childbirth. Medical error or therapeutic failure?].

Medico-legal estimation of therapeutic management in cases of perinatal complications, especially those resulting in death of the women during childbirth is usually very difficult. The authors have investigated medical documentation supported by the results of autopsies of cases chosen from the casuistry of the Forensic Medicine Department, Medical University of Silesia, Katowice. Considering the limits of professional liability and legal responsibility of physicians, close attention was paid to standard therapeutic management and increased risk in treatment with regard to that relating to typical salubrious complications. The presented cases of deaths of women during childbirth can be the succeeding opinion in broad discussion on medical errors as well as an attempt to standardise and differentiate the medical error from therapeutic failure which occurred within the reach of risk in the undertaken treatment.

Adult↗
PubMed2006

Using medical-error reporting to drive patient safety efforts.

IMPROVING PATIENT SAFETY has become one of the driving forces in health care delivery. Honest, accurate disclosure of medical errors and close calls is crucial to gain a better grasp of problems, make effective changes, and evaluate progress. ALTHOUGH FEAR OF MALPRACTICE litigation remains a major deterrent to medical-error reporting, disclosure allows organizations to benefit from one another's experiences. Accountability necessitates mandatory reporting to external organizations, but a wide variety of reporting systems exist, each with its own advantages and shortcomings. National standardized reporting is a major objective for the patient safety movement. STAFF MEMBER INVESTMENT is a key factor in the safety process and needs to extend beyond the reporting procedure.

Humans↗
PubMed2005

Study: CPOE facilitates 22 types of medication errors.

Fragmentation of data and human/machine interface are two key sources of potential errors. Make sure your system accounts for the total flow of products, services, and people. Avoid complacency; newer systems mean newer potential sources of errors.

Humans↗
PubMed1994

Use of severity-indexed medication error reports to improve quality.

A severity-indexed medication error reporting system using data from voluntary incident reports has provided enough information to target opportunities for quality improvement. Reports are ranked by severity and categorized by error type, system breakdown, drug category, and nursing unit. Specific reports are generated for review by different quality improvement committees in the hospital. Based on these data and the actions of these quality improvement committees, four problem areas in medication use have been identified. Recommendations for improvements have been made to solve problems with late IV antibiotic doses, narcotic errors, anticoagulant errors and transcription errors. Two of these initiatives have resulted in objective improvement. Two others are being actively pursued to resolve medication related problems.

Forms and Records Control↗
PubMedDate not supplied

Effect of three teaching methods on a nursing staff's knowledge of medication error risk reduction strategies.

The authors' purpose in this study was to (1) compare the effects of three teaching methods on registered nurses' and licensed practical nurses' knowledge of medication error risk reduction strategies, and (2) to compare registered nurses' and licensed practical nurses' knowledge of medication error risk reduction strategies using a pretest/posttest design. Registered nurses (n = 129) and licensed practical nurses (n = 21) employed by two hospitals constituted the study sample. Subjects were assigned alternately to three intervention groups: videotape (n = 50); instructional booklet (n = 50); and lecture (n = 50). A 38-item test, including true-false, multiple choice, matching items and dosage calculation problems, was administered to subjects in each group before and after the teaching intervention. On the basis of the results, there was no statistically significant difference in total knowledge scores for the three intervention groups (F = 2.07, P = 0.130). Staff development instructors should consider the advantages of a videotape and instructional booklet over the time-intensive lecture strategy.

Adult↗
PubMedDate not supplied

Examining medication errors in a tertiary hospital.

This project examined the accuracy of medication administration by nurses at a large tertiary hospital. Registered nurses were prepared to directly observe medication administration. Observations were made of 1514 doses administered by 30 nurses on 3 units, on day and evening shifts. Few (5%) medication errors were found. The most frequent errors were wrong technique, wrong time, and omission. Results suggest examination of medication policies, assessment of medication administration competency, and targeted in-service education.

Adverse Drug Reaction Reporting Systems↗
PubMed2004

Preventing medication errors with smart infusion technology.

PURPOSE: Processes that pharmacists can use to identify high-risk areas and drugs that require special focus in error-prevention efforts are discussed, with emphasis on the need for i.v. medication error prevention. SUMMARY: Pharmacists can help determine where best to focus medication safety efforts and innovative technology by identifying areas that pose the greatest risk of harm to a patient, such as medications, administration routes, patient care areas, and diagnosis-related groups. Delivery of i.v. medications via infusion devices has traditionally not been a major concern for pharmacists. The introduction of "smart" infusion technology has changed that paradigm by requiring pharmacist involvement in defining minimum and maximum doses for continuous and bolus infusions used within a health care facility. This technology provides a software filter to prevent key-stroke errors in programming infusion devices for delivery of i.v. drugs, as well as a new source of data with which to measure medication errors at the bedside. Implementation of smart infusion technology at Vanderbilt University Medical Center appeared to prevent errors involving heparin. In addition to having an immediate positive impact at the bedside, the technology was relatively easy to implement. CONCLUSION: Smart infusion systems represent an innovative technology that can provide an additional layer of protection at the point of care to help avert i.v. drug errors and prevent patient harm.

Biomedical Technology↗
PubMedDate not supplied

Choosing your words carefully: how physicians would disclose harmful medical errors to patients.

BACKGROUND: A gap exists between patients' desire to be told about medical errors and present practice. Little is known about how physicians approach disclosure. The objective of the present study was to describe how physicians disclose errors to patients. METHODS: Mailed survey of 2637 medical and surgical physicians in the United States (Missouri and Washington) and Canada (national sample). Participants received 1 of 4 scenarios depicting serious errors that varied by specialty (medical and surgical scenarios) and by how obvious the error would be to the patient if not disclosed (more apparent vs less apparent). Five questions measured what respondents would disclose using scripted statements. RESULTS: Wide variation existed regarding what information respondents would disclose. Of the respondents, 56% chose statements that mentioned the adverse event but not the error, while 42% would explicitly state that an error occurred. Some physicians disclosed little information: 19% would not volunteer any information about the error's cause, and 63% would not provide specific information about preventing future errors. Disclosure was affected by the nature of the error and physician specialty. Of the respondents, 51% who received the more apparent errors explicitly mentioned the error, compared with 32% who received the less apparent errors (P<.001); 58% of medical specialists explicitly mentioned the error, compared with 19% of surgical specialists (P<.001). Respondents disclosed more information if they had positive disclosure attitudes, felt responsible for the error, had prior positive disclosure experiences, and were Canadian. CONCLUSIONS: Physicians vary widely in how they would disclose errors to patients. Disclosure standards and training are necessary to meet public expectations and promote professional responsibility following errors.

Attitude of Health Personnel↗
PubMed2005

Medical error prevention in ED triage for ACS: use of cardiac care decision support and quality improvement feedback.

Medical errors in the care of patients who present with acute coronary syndrome (ACS)include errors in emergency department (ED) triage, such as the decision to send home a patient who presents with ACS or to hospitalize a patient who does not have ACS to the cardiac care unit (CCU), and errors in treatment, such as the failure to promptly use reperfusion therapy for patients who present with ST-elevation acute myocardial infarction(AMI). ECG-based acute cardiac ischemia time-insensitive predictive instrument(ACI-TIPI) and thrombolytic predictive instruments (TPIs), with a linked TIPI information system (TIPI-IS), provide real-time, concurrent, and retrospective decision support tools and feedback for the prevention of medical errors in the care of patients who present with ACS. In real-time, ACI-TIPI probabilities printed on the ECG header for the ED physician, provide an additional piece of information for triage decision making, and the ACI-TIPI Risk Management form reduces liability risk by prompting consideration and documentation of key clinical factors in the diagnosis of ACI. Also in real-time, the TPI increases overall coronary reperfusion therapy use. Concurrent flagging by TIPI-IS uses electronically acquired ECG and hospital data to provide concurrent alerts about potential misdiagnosis or mis-triage of patients with ACS. Retrospectively TIPI-IS-based feedback reports allow performance improvement. These examples of information technology tools integrated into ECG equipment already used in hospitals to deliver patient care demonstrate the potential to adapt other existing equipment or other patient care activities to enhance patient safety and error reduction.

Acute Disease↗