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"Medical error"

Chanu Rhee, Travis M Jones, Yasir Hamad, Anupam Pande, Jack Varon, Cara O'Brien, Deverick J Anderson, David K Warren, Raymund B Dantes, Lauren Epstein, Michael Klompas
Importance: Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown. Objective: To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals. Design, Setting, and Participants: Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted...
February 1, 2019: JAMA network open
Kerri Cooper, Emma Hatfield, James Yeomans
BACKGROUND: Storytelling is a powerful form of communication which can improve attention and lead to lasting behavioural changes. Addressing the need to incorporate patient safety teaching into undergraduate medical curricula, it was hypothesized that medical students could benefit from hearing clinician stories of medical error. The medium of animation was considered to be a potentially engaging means of presenting stories of error to a large audience. METHODS: Three animated videos were developed to accompany audio recordings of junior doctors describing their experiences of a serious incident or near-miss event...
February 14, 2019: Perspectives on Medical Education
Waleed Alharbi, Jennifer Cleland, Zoe Morrison
Objective: Adverse events which result from medication errors are considered to be one of the most frequently encountered patient safety issues in clinical settings. We undertook a qualitative investigation to identify and explore factors relating to medication error in an adult oncology department in Saudi Arabia from the perspective of healthcare professionals. Methods: This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining required ethical approvals and written consents from the participants, semi-structured interviews and focus group discussions were carried out for data collection...
February 2019: Saudi Pharmaceutical Journal: SPJ: the Official Publication of the Saudi Pharmaceutical Society
Kimberly Scherer, Ronald S Winokur
Efficient teamwork and communication is critical for the delivery of safe and high quality patient care. Studies have shown that medical errors can occur as a result of poor communication. Simulation scenarios can help improve communication and teamwork, therefore decreasing errors and improving team morale. Simulation is best employed through a multidisciplinary approach, including all members of the team involved in the patient's care. Team simulation can be difficult to plan and execute, therefore we will review the steps to planning an effective multidisciplinary team simulation, as well as the barriers to overcome when implementing these programs...
March 2019: Techniques in Vascular and Interventional Radiology
Ingrid Philibert, Elizabeth Elsey, Simon Fleming, Saleem Razack
PURPOSE: We examined studies of the clinical learning environment from the fields of sociology and organizational culture to (i) offer insight into how workplace culture has informed research on postgraduate trainee learning and professional development; (ii) highlight limitations of the literature; and (iii) suggest practical ways to apply sociocultural concepts to challenges in the learning environment. MATERIALS AND METHODS: Concepts were explored by participants at a consensus conference in October 2018...
February 14, 2019: Medical Teacher
M Novi, C Vanni, P D Parchi, M Di Paolo, N Piolanti, M Scaglione
PURPOSE: Over the years, the number of total hip replacements has been steadily increasing. Despite the improvement in surgical results, the number of claims for malpractice is higher. The primary endpoint of this work is to provide an analysis of litigation after hip replacement, to outline what are the instigating causes and costs. The secondary endpoint is to propose a possible preventive strategy for an improved care and a reduction in legal proceedings. MATERIALS AND METHODS: The data of this study were collected from medical and legal files and from professional liability insurance of our institution from January 2005 to December 2016...
February 13, 2019: Musculoskeletal Surgery
Lisa Brockhaus, Yasmin Schmid, Anna C Rast, Alexandra E Rätz Bravo, Kathrin Scherer Hofmeier, Anne B Leuppi-Taegtmeyer
BACKGROUND: True hypersensitivity reactions to rifampicin are relatively rare, nonetheless severe manifestations mostly involving a single organ have been documented. We report a case of acute multi-organ failure occurring after a medication error with re-exposure to rifampicin. CASE PRESENTATION: A 68-year old patient developed acute hypersensitivity pneumonitis, acute renal failure, acute liver failure and haemolytic anemia within hours after a second re-exposure to Rifampicin for the treatment of a hip prosthesis infection with Staphylococcus epidermidis...
February 12, 2019: BMC Pharmacology & Toxicology
James B Leonard, Wendy Klein-Schwartz
No abstract text is available yet for this article.
February 9, 2019: American Journal of Health-system Pharmacy: AJHP
James S Wheeler, Chelsea P Renfro, Junling Wang, Yanru Qiao, Kenneth C Hohmeier
OBJECTIVES: To compare viewpoints of nationally certified and noncertified technicians and explore the perceived value of technician certification in the job performance domains of medication safety, skills and abilities, experience, engagement and satisfaction, and productivity. METHODS: A cross-sectional survey of pharmacy technicians, from 6 states representing 4 regions of the United States, was conducted. Technician mailing lists were purchased from Boards of Pharmacy, and randomly selected technicians were sent survey invitations...
February 8, 2019: Journal of the American Pharmacists Association: JAPhA
Maryati Mohd Yusof
The evaluation of Health Information Systems (HIS)-induced medication errors is crucial in efforts to understand its cause, impact and mitigation measures when trying to minimize errors and increase patient safety. A review of evaluation studies on HIS-induced medication errors was carried out, which indicated the need to further structure complex socio technical aspects of the subject. In order to satisfy this requirement, a new framework was introduced for the evaluation of HIS-induced error management in clinical settings...
2019: Studies in Health Technology and Informatics
Melody Penning, Mary Gadde, Meredith Zozus
The detection of adverse events (AE) and their relationship to data quality issues through processes or medical error is not currently understood. In order to study the relationship between adverse events and data quality it is necessary to capture as many AE as possible and computational methods will be necessary to handle the large volumes of patient data. The need for adverse event detection methodology has been repeatedly noted but standard AE detection methods are not in place in the US. At present, there are several widely enforced strategies for AE detection but none are both highly successful and computational...
2019: Studies in Health Technology and Informatics
Shefali Haldar, Sonali R Mishra, Maher Khelifi, Ari H Pollack, Wanda Pratt
Healthcare systems worldwide have dedicated several years, special attention, and action toward improving safety for their patients. Although many innovative technological solutions have helped providers reduce medical errors, hospitalized patients lack access to these solutions, and face difficulties in having a proactive role in their safety. In this paper, we examine how patient-peer support can be a valuable resource for patients in the context of hospital safety. Through semi-structured interviews with 30 patients and caregivers at a pediatric and an adult hospital, we identify the potential benefits of incorporating patient-peer support into patient-facing technologies...
2019: Studies in Health Technology and Informatics
Keval Dabba, Matthew Elswood, Ahmed Ameer, David Gerrett, Ian Maidment
PURPOSE: To review and analyse medication errors related to clozapine, an atypical antipsychotic, that were reported to the National Reporting and Learning System (NRLS). METHODS: Following extraction of one year of clozapine related errors from the NRLS, a qualitative analysis (thematic analysis and re-classification) and quantitative analysis was performed. An incident was considered a clozapine error if there was a failure in its medication process (i.e. an error in the prescribing, dispensing, preparing, administering, monitoring or advising of clozapine)...
February 10, 2019: Pharmacoepidemiology and Drug Safety
Alexander M Mozeika, Devika Sachdev, Rijul Asri, Nicole Farber, Boris Paskhover
PURPOSE: Medical error in the United States carries substantial economic and safety costs, which manifest in a large number of malpractice suits filed each year. The aim of this study was to characterize the various sociologic and medical factors that influence malpractice suits occurring from cases of facial trauma. MATERIALS AND METHODS: This retrospective cohort study examined defendant data from facial trauma malpractice cases extracted from the Westlaw database, a database composed of representative federal litigations...
January 15, 2019: Journal of Oral and Maxillofacial Surgery
Obada Hasan, Ahmed Ayaz, Muneeba Jessar, Charles Docherty, Pervaiz Hashmi
Operative skills are the heart and soul of surgical practice. An extensive amount of literature has been devoted to the art and science of acquiring these skills which start by mastering basic skills until automaticity has been achieved. The current model of surgical education is purely based on sheer volume of patients, restrictions in the maximum number of working hours for trainees and increased pressures of operating room efficiency. This leads to limited teaching time. Adding to the scenario is the emphasis on patient safety and greater awareness of medico-legal consequences following medical errors...
February 2019: JPMA. the Journal of the Pakistan Medical Association
Ghadah A Assiri, Abdullah Hm Alkhenizan, Salma A Al-Khani, Liz M Grant, Aziz Sheikh
OBJECTIVES: To investigate the period prevalence and risk factors for clinically important prescription and monitoring errors among adults managed in community care in Saudi Arabia (SA). METHODS: This retrospective cohort study used electronic health record (HER) data. A random sample comprising of 2,000 adults (≥18 years old) visiting Family Medicine clinics in King Faisal Specialist Hospital and Research Center (KFSH & RC), Riyadh, SA, was selected...
February 2019: Saudi Medical Journal
Meghan Fletcher, Shannon Rankin, Preeyaporn Sarangarm
Background: Tetanus vaccinations for wound prophylaxis are routinely administered in emergency departments (ED). Current recommendations from the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) regarding tetanus administration for wound prophylaxis differentiate between the tetanus and diphtheria (Td) and the tetanus, diphtheria, acellular pertussis (Tdap) formulations and when they should be administered. Lack of knowledge regarding these recommendations, different formulations, and techniques to locate patient immunization history can lend to increased duplicate and inappropriate vaccinations...
February 2019: Hospital Pharmacy
David J Taber, Mulugeta Gebregziabher, Aurora Posadas, Caitlin Schaffner, Leonard E Egede, Prabhakar K Baliga
Introduction: Health disparities in African-American (AA) kidney transplant recipients compared with non-AA recipients are well established. Cardiovascular disease (CVD) risk control is a significant mediator of this disparity. Objective: To assess the efficacy of improved medication safety, CVD risk control, and racial disparities in kidney transplant recipients. Methods: Prospective, pharmacist-led, technology-aided, 6-month interventional clinical trial...
December 2018: Journal of the American College of Clinical Pharmacy: JAACP
Chu-Ya Huang, Phung-Anh Nguyen, Hsuan-Chia Yang, Md Mohaimenul Islam, Chia-Wei Liang, Fei-Peng Lee, Yu-Chuan Jack Li
OBJECTIVES: Medication-related clinical decision support systems have already been considered as a sophisticated method to improve healthcare quality, however, its importance has not been fully recognized. This paper's aim was to validate an existing probabilistic model that can automatically identify medication errors by performing a sensitivity analysis from electronic medical record data. METHODS: We first built a knowledge base that consisted of 2.22 million disease-medication (DM) and 0...
March 2019: Computer Methods and Programs in Biomedicine
Kathleen Wyatt Chester, Megan Corrigan, J Megan Schoeffler, Michelle Shah, Florence Toy, Barbara Purdon, George M Dillon
Alteplase, reteplase, and tenecteplase are tissue plasminogen activators (TPA) approved for the management of acute myocardial infarction. Only alteplase is also approved for the treatment of acute ischemic stroke (AIS). The US Food and Drug Administration has received reports of accidental administration of tenecteplase or reteplase instead of alteplase in patients with AIS, which can result in failure to treat patients with the intended agent and lead to potential overdose. Areas covered: This review compares the molecular and clinical features of alteplase, reteplase, and tenecteplase (TNK), identifies factors contributing to medication errors among these agents, and provides steps to reduce medication errors...
February 4, 2019: Expert Opinion on Drug Safety
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