465,732 research outputs found
Process Improvement to Reduce Route of Medication Administration Errors in Patients with Enteral Feeding Tubes
Advances in health information management in the form electronic health records, computerized provider order entry systems, and clinical decision support systems and tools have enhanced the productivity, effectiveness, and efficiency of healthcare. However, the cost of these positive effects does come at the expense of other factors. Along with the introduction of Clinical Provider Order Entry (CPOE) systems, organizations have experienced new possibilities for medication errors and risks to patient safety. Factors associated with these errors should be evaluated in detail in order to mitigate the causes of these types of errors and to plan strategies for prevention. Continued research into how to improve the quality of these systems is necessary to promote the usability and acceptance of CPOE systems by prescribers and to continue to make an impact on the frequency of medication errors within health care organizations.
Health care organizations must develop strategies to improve the rate of medication errors caused by CPOE systems. Strategies may vary from organization to organization, and depend upon organization-specific resources. Ideally, a plan to improve patient safety and prevent errors related to CPOE systems would include stakeholders such as the clinical team and providers, involve a system that can audit the frequency of errors, and include ongoing education about the problem and the proposed solution. A plan to prevent errors and improve patient safety that is not-dependent upon the intricacies of a specific electronic medical record is ideal. A strategy that can carry-over from one electronic medical record system to the next and that can address the central problem with accuracy, efficiency, and evidence-based research will be proposed
Committed to Safety: Ten Case Studies on Reducing Harm to Patients
Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations
Weaving the Fabric of Patient Safety
It is critical to support Colorado's leaders in health care, business and government to build a culture of safety, ensure safe and efficient transitions of care, and foster the creation of a Patient Safety Organization. This summary -- developed by the Colorado Patient Safety Leadership Task Force with support from The Colorado Trust -- provides a roadmap for patient safety activities in Colorado. The complete agenda, Weaving the Fabric of Patient Safety in Colorado, is available from the Colorado Patient Safety Coalition
Are We Making Smart Pumps Smarter?
Background: Medication errors comprise a significant proportion of medical errors, and are abundant, costly, and associated with causing harm to patients via adverse drug events. The most serious medication errors often involve IV medications. Smart pumps were developed to improve patient safety by reducing medication errors. While some studies have found that smart pumps do not decrease medication errors, most have found they are effective to some degree. It is believed that routinely analyzing data on smart pump alerts, making corresponding adjustments in the drug libraries, and analyzing those adjustments can reduce alarm fatigue, which may then decrease medication errors by resulting in less smart pump users overriding the alerts and utilizing workarounds of smart pump safety features.
Objective: The objective of this study is to assess if changes made to the Indiana University Health system smart pump drug library decreased nuisance alerts by comparing the actions taken in response to alerts before and after the changes were made.
Methods: For a given change made to the Indiana University Health smart pump drug library on April 1, 2016, actions taken in response to alerts corresponding to that change three months prior to and three months after the change were analyzed. The primary outcome was the percent of total alerts that were overrides. Using data from the smart pumps, the number of overrides, reprograms, cancels, and total alerts for each drug in the first and second quarter were recorded. The percentage of total alerts that were overrides, the percentage of total alerts that were reprograms, and the ratio of overrides to reprograms for each quarter were calculated.
Results: Analysis was conducted on 8 drugs: carboplatin, fentanyl PCA, hydromorphone PCA, morphine PCA, morphine PCA 10-24kg, morphine PCA \u3e40kg, naloxone, and octreotide. From the first quarter to the second quarter, the percent of overrides increased for 3 drugs, but for all 3, the number of overrides and total alerts decreased. Of the 5 drugs that had a decrease in the percent of overrides, 3 had an increase in the number of overrides and total alerts. Only 2 drugs had a decrease in the percent of overrides and the number of overrides and total alerts. Statistical significance was achieved only for hydromorphone PCA and morphine PCA. The difference between the first and second quarters in the all the measured outcomes varied between the drugs.
Conclusions: Forming any definitive conclusions was difficult due to the results containing a significant amount of variation. The literature suggests methods to improve smart pump usage, and improve medication safety by extension. These methods are interfacing smart pumps with computerized physician order entry, clinical decision support systems, electronic medical record/electronic medication administration record, pharmacy information systems, bar-coded medication administration, and laboratory data, as well as improving smart pump safety features compliance through education of smart pump users, leadership support, including/consulting smart pump users in drug library design, and routinely using the event log data as a component of a continuous quality improvement program. These methods are all in line with the current, trending belief that the best method for preventing medication errors is making changes to the medication use system as a whole to correct underlying systems failures instead of addressing a single point, such a smart pump alerts
Is There an App for That? Electronic Health Records (EHRs) and a New Environment of Conflict Prevention and Resolution
Katsh discusses the new problems that are a consequence of a new technological environment in healthcare, one that has an array of elements that makes the emergence of disputes likely. Novel uses of technology have already addressed both the problem and its source in other contexts, such as e-commerce, where large numbers of transactions have generated large numbers of disputes. If technology-supported healthcare is to improve the field of medicine, a similar effort at dispute prevention and resolution will be necessary
The Great Medical Malpractice Hoax: NPDB Data Continue to Show Medical Liability System Produces Rational Outcomes
Despite claims by business and medical lobbying interests and the Bush administration, there is no medical malpractice lawsuit crisis in America, according to this report by Public Citizen. The report dispels oft-repeated myths of dwindling doctors and spiraling insurance premiums used to support limits on the ability of injured patients to seek redress in the courts.The real problems are a lack of attention to patient safety, the high incidence of preventable medical error and the lack of accountability for a small set of doctors who account for a majority of medical malpractice payments, the report reveals. The report also presents several recommendations for Congress, state governments and hospitals to reduce health care costs and save lives.Public Citizen reviewed publicly available information from 1990 to 2005 from the federal government's National Practitioner Data Bank (NPDB), which contains data on malpractice payments made on behalf of doctors as well as disciplinary actions taken against them by state medical boards or hospitals. According to the analysis, the total number of malpractice payments paid on behalf of doctors, with judgments and settlements, declined 15.4 percent between 1991 and 2005, and the number of payments per 100,000 people in the country declined more than 10 percent. In addition, the average payment for a medical malpractice verdict, adjusted for inflation, dropped eight percent in the same period.The numbers show that patients do not win large jury awards for less serious claims but that payments usually correspond to the severity of injury. In 2005, less than three percent of all payments were for million-dollar verdicts and more than 64 percent of payments involved death or significant injury -- while less than one-third of one percent were for "insignificant injury.
A safer place for patients: learning to improve patient safety
1 Every day over one million people are treated
successfully by National Health Service (NHS) acute,
ambulance and mental health trusts. However, healthcare
relies on a range of complex interactions of people,
skills, technologies and drugs, and sometimes things do
go wrong. For most countries, patient safety is now the
key issue in healthcare quality and risk management.
The Department of Health (the Department) estimates
that one in ten patients admitted to NHS hospitals will be
unintentionally harmed, a rate similar to other developed
countries. Around 50 per cent of these patient safety
incidentsa could have been avoided, if only lessons from
previous incidents had been learned.
2
There are numerous stakeholders with a role in
keeping patients safe in the NHS, many of whom require
trusts to report details of patient safety incidents and near
misses to them (Figure 2). However, a number of previous
National Audit Office reports have highlighted concerns
that the NHS has limited information on the extent and
impact of clinical and non-clinical incidents and trusts need
to learn from these incidents and share good practice across
the NHS more effectively (Appendix 1).
3 In 2000, the Chief Medical Officer’s report An
organisation with a memory
1
, identified that the key
barriers to reducing the number of patient safety incidents
were an organisational culture that inhibited reporting and
the lack of a cohesive national system for identifying and
sharing lessons learnt.
4 In response, the Department published Building a
safer NHS for patients3 detailing plans and a timetable
for promoting patient safety. The goal was to encourage
improvements in reporting and learning through the
development of a new mandatory national reporting
scheme for patient safety incidents and near misses. Central
to the plan was establishing the National Patient Safety
Agency to improve patient safety by reducing the risk of
harm through error. The National Patient Safety Agency was
expected to: collect and analyse information; assimilate
other safety-related information from a variety of existing
reporting systems; learn lessons and produce solutions.
5 We therefore examined whether the NHS has
been successful in improving the patient safety culture,
encouraging reporting and learning from patient safety
incidents. Key parts of our approach were a census of
267 NHS acute, ambulance and mental health trusts in
Autumn 2004, followed by a re-survey in August 2005
and an omnibus survey of patients (Appendix 2). We also
reviewed practices in other industries (Appendix 3) and
international healthcare systems (Appendix 4), and the
National Patient Safety Agency’s progress in developing its
National Reporting and Learning System (Appendix 5) and
other related activities (Appendix 6).
6 An organisation with a memory1
was an important
milestone in the NHS’s patient safety agenda and marked
the drive to improve reporting and learning. At the
local level the vast majority of trusts have developed a
predominantly open and fair reporting culture but with
pockets of blame and scope to improve their strategies for
sharing good practice. Indeed in our re-survey we found
that local performance had continued to improve with more
trusts reporting having an open and fair reporting culture,
more trusts with open reporting systems and improvements
in perceptions of the levels of under-reporting. At the
national level, progress on developing the national reporting
system for learning has been slower than set out in the
Department’s strategy of 2001
3
and there is a need to
improve evaluation and sharing of lessons and solutions by
all organisations with a stake in patient safety. There is also
no clear system for monitoring that lessons are learned at the
local level. Specifically:
a The safety culture within trusts is improving, driven
largely by the Department’s clinical governance
initiative
4
and the development of more effective risk
management systems in response to incentives under
initiatives such as the NHS Litigation Authority’s
Clinical Negligence Scheme for Trusts (Appendix 7).
However, trusts are still predominantly reactive in
their response to patient safety issues and parts of
some organisations still operate a blame culture.
b All trusts have established effective reporting systems
at the local level, although under-reporting remains
a problem within some groups of staff, types of
incidents and near misses. The National Patient Safety
Agency did not develop and roll out the National
Reporting and Learning System by December 2002
as originally envisaged. All trusts were linked to the
system by 31 December 2004. By August 2005, at
least 35 trusts still had not submitted any data to the
National Reporting and Learning System.
c Most trusts pointed to specific improvements
derived from lessons learnt from their local incident
reporting systems, but these are still not widely
promulgated, either within or between trusts.
The National Patient Safety Agency has provided
only limited feedback to trusts of evidence-based
solutions or actions derived from the national
reporting system. It published its first feedback report
from the Patient Safety Observatory in July 2005
What You Need to Know about Bar-Code Medication Administration
Medication errors are the most common type of preventable error. Bar-code medication administration (BCMA) technology was designed to reduce medication administration errors. Poor system design, implementation and workarounds remain a cause of errors. This paper reviews the literature on BCMA, identifies a gap in the findings and identifies three evidence based practices that could be used to improve system implementation and reduce error. The literature review identified that Bar-code medication administration and system workarounds are well documented and affect patient safety. Based on the critical analysis of 10 studies, we identified gaps in the standardization of BCMA planning, implementation, and sustainability. The themes that emerged from the literature were poor BCMA design and implementation that resulted in workarounds.The three evidence based strategies proposed to address this gap are, evidence based standardization in planning and implementation, the identification and elimination of workarounds and hard wiring. An evidence based checklist evaluates compliance with standard procedures. The LEAN model of Jodoka is used to assure adaptation of the machine to human workflow. Direct observation provides valuable workflow assessment. An effective BCMA implementation involves careful system design, identification of workflow issues which cause workarounds, and adapting the machine to nursing needs
The role of incident reporting in continuous quality improvement in the intensive care setting
Publisher's copy made available with the permission of the publisherU. Beckman, W.B. Runcimanhttp://www.aaic.net.au/Article.asp?D=199606
- …