Association between limiting the number of open records in a tele-critical care setting and retract–reorder errors

BackgroundWrong patient selection errors may be tracked by retract–reorder (RAR) events. The aim of this quality improvement study was to assess the impact of reducing the number of concurrently open electronic health records from 4 to 2 on RAR errors generated by a tele-critical care service.MethodsThe study encompassed 32 months before and 21 months after restriction. Chi-Square test of proportions and T statistical process control chart for rare events were used.ResultsThere were 156 318 orders with 57 RAR errors (36.5/100 000 orders) before restriction, and 122 587 orders with 34 errors (27.7/100 000 orders) after. Rates were not statistically different (P = .20), but analysis was underpowered. When plotted on a T control chart, random variation was detected between RAR errors.ConclusionWe found no significant difference in RAR errors in the tele-critical care setting after open record limitation. Other strategies should be studied to reduce wrong patient selection errors.     

Medication errors—an enduring problem for children and elderly patients

Abstract

Objective. To analyze the types and reasons of medication errors, committed by health care professionals, which led to toxicological consultations at the Czech Toxicological Information Centre (TIC).

Methods. Inquiries arising from medication errors for 2000–2010 were extracted and evaluated from the database of the TIC, recording the consultations of poisonings due to drugs, household products, plants, and mushrooms.

Results. From a total of 44,344 calls concerning pharmaceuticals, 215 (0.5%) were denoted by the caller as medication errors; 130 involved children (90 below 5 years of age) and 85 involved adults (30–60 years of age). The most common errors were: improper dosage (60.9%), wrong medication (19.3%), or erroneous route of administration (12.9%). The most frequent medication errors appeared using drugs affecting the nervous system (psycholeptics and antiepileptics), antibiotics, and drugs affecting the respiratory system. Nurses administering the drugs were responsible for 43.0%, physicians prescribing the drugs for 36.8%, and pharmacists dispensing the drugs for 20.2% of the errors. Of 25 patients with severe drug intoxications, 60.0% were children under 5 years of age treated with pharmaceuticals affecting the CNS, and 28.0% patients over 60 years of age with chronic application of theophylline, digoxin, or lithium.

Conclusions. The trend in medication errors has remained relatively stable over the past 11 years. The analysis of medication errors shows two high-risk categories: children of less than 5 years of age, in whom the dose was not correctly adjusted, and elderly people with chronic medication and insufficient control of their medication level. Therefore, the measures for risk reduction should focus primarily on them.     

Impact of personal protective equipment on patient safety and health care workers

BackgroundThe study aims to assess the effect of personal protective equipment (PPE) on the physical and psychological well-being of health care workers (HCWs) and its impact on patient safety.MethodsAfter ethical approval, a 14-point questionnaire was circulated offline and online among the HCWs of ours institute, who were involved in performing invasive procedures while wearing a PPE. The responses were analysed using the SPSS software version 26.ResultsOf 198 responses, the mean duration of PPE use was 4.6 ± 1.52 h. Seventy percent of respondents suggested <4 h of continuous use of PPE. Seventy-seven percent found difficulties during the procedures while wearing PPE and agreed to errors while performing a procedure. Poor visibility (95.5%), fogging (84.9%), communication difficulty (75.3%), sweating (74.2%), posture-related discomfort (56.1%) and poor concentration (51%) were major causes. Anxiety (39.9%) and fear of spreading an infection to the family (42.9%) were major psychological effects. Eighty percent of HCWs raised concern over the quality of PPE, N95 mask and eye protector. The HCWs felt the need to improve the quality of PPEs, use extra padding around the ears, sealing the N95 mask with adhesive tape, besides using sign language for communication for more safety. Fifty percent graded the procedure-related difficulty level >6 on a Likert scale of 1–10.ConclusionPPE-related discomfort is common among the HCWs and could contribute to errors during an invasive procedure. Efforts to alleviate the physical and psychological well-being of the HCWs will be essential for reducing procedural error while wearing a PPE.     

Unprofessional behaviour of junior doctors: a retrospective analysis of outcomes by the Singapore Medical Council disciplinary tribunals

INTRODUCTIONThis is a retrospective analysis of outcomes by Singapore Medical Council (SMC) disciplinary tribunals in cases involving junior doctors. We aimed to classify the types of unprofessional behaviour and consider appropriate measures for remediation and prevention.METHODSSMC’s annual reports from 1979 to 2017 and published grounds of decision from 2008 to 2017 were examined using two screening levels to identify cases involving junior doctors. Cases were sorted into five outcome categories: (a) professional misconduct; (b) fraud and dishonesty; (c) defect in character; (d) disrepute to the profession; and (e) acquitted.RESULTSA total of 317 cases were identified, of which 13 (4.1%) involved junior doctors: 4 (30.8%) cases involved professional misconduct, 4 (30.8%) cases involved fraud and dishonesty, 3 (23.1%) cases saw an acquittal, and one case each involved defect in character and disrepute to the profession. The four cases of professional misconduct highlight the need to differentiate medical errors due to systems factors from those due to individual culpability, by applying analytical tools such as root cause analysis and Unsafe Act Algorithms. Disciplining the individual alone does not help prevent the recurrence of similar medical errors. We found that fraud and dishonesty was an important category of unprofessional behaviour among junior doctors.CONCLUSIONWhile the frequency of unprofessional behaviour among junior doctors, as determined by the SMC disciplinary tribunal, is low (4.1%), this study highlights that complaints against medical doctors often involve systems issues and individual factors. Unprofessional behaviours related to fraud and dishonesty need special attention in medical school.     

Quantitative assessment of prevalence of pre-analytical variables and their effect on coagulation assay. Can intervention improve patient safety?

BackgroundVery few Indian studies exist on evaluation of pre-analytical variables affecting “Prothrombin Time” the commonest coagulation assay performed. The study was performed in an Indian tertiary care setting with an aim to assess quantitatively the prevalence of pre-analytical variables and their effects on the results (patient safety), for Prothrombin time test. The study also evaluated their effects on the result and whether intervention, did correct the results.MethodsThe firstly evaluated the prevalence for various pre-analytical variables detected in samples sent for Prothrombin Time testing. These samples with the detected variables wherever possible were tested and result noted. The samples from the same patients were repeated and retested ensuring that no pre-analytical variable is present. The results were again noted to check for difference the intervention produced.ResultsThe study evaluated 9989 samples received for PT/INR over a period of 18 months. The prevalence of different pre-analytical variables was found to be 862 (8.63%). The proportion of various pre-analytical variables detected were haemolysed samples 515 (5.16%), over filled vacutainers 62 (0.62%), under filled vacutainers 39 (0.39%), low values 205 (2.05%), clotted samples 11 (0.11%), wrong labeling 4 (0.04%), wrong vacutainer use 2 (0.02%), chylous samples 7 (0.07%) and samples with more than one variable 17 (0.17%). The comparison of percentage of samples showing errors were noted for the first variables since they could be tested with and without the variable in place. The reduction in error percentage was 91.5%, 69.2%, 81.5% and 95.4% post intervention for haemolysed, overfilled, under filled and samples collected with excess pressure at phlebotomy respectively.ConclusionCorrecting the variables did reduce the error percentage to a great extent in these four variables and hence the variables are found to affect “Prothrombin Time” testing and can hamper patient safety.     

How has the COVID-19 pandemic affect the rejection rates and repeat reasoning of digital radiography?

Objectives:To compare the digital radiology rejection rates and reasoning pre-COVID-19 (PC) and during COVID-19 (DC) from September 2019 to August 2020.Methods:This record-base retrospective study where data were extracted from the radiography equipment (Carestream Health, Rochester, New York, USA) at the Department of Radiology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia over 12 months. The data were equally divided into PC and DC.Results:The DC rejection rate decreased from PC by 2.6% with a significant p=0.00001. During COVID-19 there were 15,376 images of different body parts, versus 23,861 images during PC. Position errors were the main reasons for rejection for both PC (39.8%) and DC (42.7%), followed by technique errors (PC: 19.2%) (DC: 17.2%).Conclusion:Different sectors in hospitals were affected by COVID-19, including diagnostic radiology, in the positive direction. Thus, the DC rejection rate was markedly reduced compared with PC. This may be due to radiology technicians becoming more cautious in dealing with patients.     

Medication errors—an enduring problem for children and elderly patients

Objective

To analyze the types and reasons of medication errors, committed by health care professionals, which led to toxicological consultations at the Czech Toxicological Information Centre (TIC).

Methods

Inquiries arising from medication errors for 2000–2010 were extracted and evaluated from the database of the TIC, recording the consultations of poisonings due to drugs, household products, plants, and mushrooms.

Results

From a total of 44,344 calls concerning pharmaceuticals, 215 (0.5%) were denoted by the caller as medication errors; 130 involved children (90 below 5 years of age) and 85 involved adults (30–60 years of age). The most common errors were: improper dosage (60.9%), wrong medication (19.3%), or erroneous route of administration (12.9%). The most frequent medication errors appeared using drugs affecting the nervous system (psycholeptics and antiepileptics), antibiotics, and drugs affecting the respiratory system. Nurses administering the drugs were responsible for 43.0%, physicians prescribing the drugs for 36.8%, and pharmacists dispensing the drugs for 20.2% of the errors. Of 25 patients with severe drug intoxications, 60.0% were children under 5 years of age treated with pharmaceuticals affecting the CNS, and 28.0% patients over 60 years of age with chronic application of theophylline, digoxin, or lithium.

Conclusions

The trend in medication errors has remained relatively stable over the past 11 years. The analysis of medication errors shows two high-risk categories: children of less than 5 years of age, in whom the dose was not correctly adjusted, and elderly people with chronic medication and insufficient control of their medication level. Therefore, the measures for risk reduction should focus primarily on them.     

Profiling harmful medication errors in an acute Irish teaching hospital

Background

Medication error reporting systems in hospitals are faced with the challenge of processing vast numbers of reports which identify a myriad of safety issues. With such large volumes of data and limited resources it makes sense to adopt a prioritisation approach. Several published studies have focused solely on the subset of errors which cause patient harm. The majority of such research has concerned the individual analysis of criteria associated with medication errors. However, the research described here used an alternative approach which involved linking the three criteria of medication class, patient outcome, and type of error, in order to describe the medication-related scenarios presenting greatest risk to the organisation.

Aims

To identify the highest-priority medication-related risks in an acute teaching hospital. To profile harmful medication errors submitted to a voluntary reporting system in a tertiary healthcare setting in Ireland.

Methods

A database of medication errors, reported via an internal voluntary reporting system over a 5-year period, was analysed. The criteria of medication class, patient outcome and type of error were analysed separately and then cross-tabulated.

Results

The medication classes, error types and adverse patient outcomes most frequently associated with harm were identified. The cross-tabulation highlighted ten priority risk areas which accounted for the majority of patient harm.

Conclusions

A cross-tabulation strategy for prioritising medication-associated risks was successfully applied to a hospital database comprising medication errors. The profile developed for harmful medication errors in this acute tertiary healthcare setting was broadly in line with that published for error reporting systems internationally.     

Speaking up about patient-perceived serious visit note errors: Patient and family experiences and recommendations

BackgroundOpen notes invite patients and families to read ambulatory visit notes through the patient portal. Little is known about the extent to which they identify and speak up about perceived errors. Understanding the barriers to speaking up can inform quality improvements.ObjectiveTo describe patient and family attitudes, experiences, and barriers related to speaking up about perceived serious note errors.MethodsMixed method analysis of a 2016 electronic survey of patients and families at 2 northeast US academic medical centers. Participants had active patient portal accounts and at least 1 note available in the preceding 12 months.Results6913 adult patients (response rate 28%) and 3672 pediatric families (response rate 17%) completed the survey. In total, 8724/9392 (93%) agreed that reporting mistakes improves patient safety. Among 8648 participants who read a note, 1434 (17%) perceived ≥1 mistake. 627/1434 (44%) reported the mistake was serious and 342/627 (56%) contacted their provider. Participants who self-identified as Black or African American, Asian, “other,” or “multiple” race(s) (OR 0.50; 95% CI (0.26,0.97)) or those who reported poorer health (OR 0.58; 95% CI (0.37,0.90)) were each less likely to speak up than white or healthier respondents, respectively. The most common barriers to speaking up were not knowing how to report a mistake (61%) and avoiding perception as a “troublemaker” (34%). Qualitative analysis of 476 free-text suggestions revealed practical recommendations and proposed innovations for partnering with patients and families.ConclusionsAbout half of patients and families who perceived a serious mistake in their notes reported it. Identified barriers demonstrate modifiable issues such as establishing clear mechanisms for reporting and more challenging issues such as creating a supportive culture. Respondents offered new ideas for engaging patients and families in improving note accuracy.     

Fatalities from blood transfusion

From April 3, 1976, to Dec 31, 1979, one hundred thirteen fatalities were reported to the Food and Drug Administration as a sequela of the transfusion of blood or blood products. Thirty-three fatalities were due to posttransfusion hepatitis, and three involved plasmapheresis or leukopheresis donors. The remaining 77 cases were of three categories: 47 cases (61%) were due to "clerical errors" such as drawing the wrong blood specimen of giving the wrong unit of blood to the patient; eight cases consisted of genuine errors that occurred in the laboratory; and 22 cases were due to miscellaneous problems, most of which were unpreventable.     

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

ObjectiveTo conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS.Materials and MethodsWe searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed.ResultsThere was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18–8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72–0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence.Discussion and ConclusionDespite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.     

基于Cochrane风险偏倚评估工具和CONSORT中药复方声明评价中成药治疗儿童急性上呼吸道感染的随机对照试验方法学质量与报告质量

[目的] 评价近5年口服中成药治疗儿童急性上呼吸道感染随机对照试验的方法学质量和报告质量,为日后开展相关儿童临床试验提供借鉴。[方法] 系统检索中国知网（CNKI）、万方数据库、维普数据库（VIP）、美国国立医学图书馆（PubMed）、Embase数据库、Cochrane图书馆。由两人独立参照Cochrane偏倚风险评估工具及中药复方临床试验报告统一标准（CONSORT-CHM Formulas）对文献进行筛选评价及结果统计。[结果] 纳入43篇文献,23篇（53.5%）文献偏倚风险判断为不确定,20篇（46.5%）文献偏倚风险判断为高风险,无低偏倚风险的文献。总体报告质量较低,样本量计算、期中分析、试验注册和获取试验方案的方法等报告率均为0%,在产生随机分配序列的方法、随机方法细节描述、分配隐藏方法、盲法的实施、受试者筛选、基线情况的描述、结局和估计值及研究的局限性等方面报告率分别为58.1%、4.7%、14.0%、20.9%、16.3%、23.3%、9.3%、16.3%,其他条目虽有涉及但内容不完整。试验方案设计在受试者选择、疗程设置和结局指标选择及评价等方面尚有不足之处。[结论] 目前中成药治疗儿童急性上呼吸道感染的临床试验方法学设计和报告质量不高,有较大提升空间。     

Risk factors associated with medication ordering errors

ObjectiveWe utilized a computerized order entry system–integrated function referred to as “void” to identify erroneous orders (ie, a “void” order). Using voided orders, we aimed to (1) identify the nature and characteristics of medication ordering errors, (2) investigate the risk factors associated with medication ordering errors, and (3) explore potential strategies to mitigate these risk factors.Materials and MethodsWe collected data on voided orders using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. Interviews were informed by the human factors–based SEIPS (Systems Engineering Initiative for Patient Safety) model to characterize the work systems–based risk factors contributing to ordering errors; chart reviews were used to establish whether a voided order was a true medication ordering error and ascertain its impact on patient safety.ResultsDuring the 16-month study period (August 25, 2017, to December 31, 2018), 1074 medication orders were voided; 842 voided orders were true medication errors (positive predictive value = 78.3 ± 1.2%). A total of 22% (n = 190) of the medication ordering errors reached the patient, with at least a single administration, without causing patient harm. Interviews were conducted on 355 voided orders (33% response). Errors were not uniquely associated with a single risk factor, but the causal contributors of medication ordering errors were multifactorial, arising from a combination of technological-, cognitive-, environmental-, social-, and organizational-level factors.ConclusionsThe void function offers a practical, standardized method to create a rich database of medication ordering errors. We highlight implications for utilizing the void function for future research, practice and learning opportunities.     

Research and applications: The safety of electronic prescribing: manifestations,mechanisms, and rates of system-related errors associated with two commercial systems in hospitals

Objectives

To compare the manifestations, mechanisms, and rates of system-related errors associated with two electronic prescribing systems (e-PS). To determine if the rate of system-related prescribing errors is greater than the rate of errors prevented.

Methods

Audit of 629 inpatient admissions at two hospitals in Sydney, Australia using the CSC MedChart and Cerner Millennium e-PS. System related errors were classified by manifestation (eg, wrong dose), mechanism, and severity. A mechanism typology comprised errors made: selecting items from drop-down menus; constructing orders; editing orders; or failing to complete new e-PS tasks. Proportions and rates of errors by manifestation, mechanism, and e-PS were calculated.

Results

42.4% (n=493) of 1164 prescribing errors were system-related (78/100 admissions). This result did not differ by e-PS (MedChart 42.6% (95% CI 39.1 to 46.1); Cerner 41.9% (37.1 to 46.8)). For 13.4% (n=66) of system-related errors there was evidence that the error was detected prior to study audit. 27.4% (n=135) of system-related errors manifested as timing errors and 22.5% (n=111) wrong drug strength errors. Selection errors accounted for 43.4% (34.2/100 admissions), editing errors 21.1% (16.5/100 admissions), and failure to complete new e-PS tasks 32.0% (32.0/100 admissions). MedChart generated more selection errors (OR=4.17; p=0.00002) but fewer new task failures (OR=0.37; p=0.003) relative to the Cerner e-PS. The two systems prevented significantly more errors than they generated (220/100 admissions (95% CI 180 to 261) vs 78 (95% CI 66 to 91)).

Conclusions

System-related errors are frequent, yet few are detected. e-PS require new tasks of prescribers, creating additional cognitive load and error opportunities. Dual classification, by manifestation and mechanism, allowed identification of design features which increase risk and potential solutions. e-PS designs with fewer drop-down menu selections may reduce error risk.     

Risk Factors for Anesthesia-Related Airway Patient Safety Incidents: A Single-Center Retrospective Case-Control Analysis from 2009 to 2022

ObjectiveAirway-related patient safety incident (PSI) has always been the top concern of anesthesiologists because this type of incidents could severely threaten patient safety if not treated immediately and properly. This study intends to reveal the composition, prognosis, and to identify risk factors for airway related incidents reported by anesthesiologists.MethodsAll airway related PSIs reported by anesthesiologists in a Chinese academic hospital between September 2009 and May 2022 were collected from the PSI reporting system. Patients with airway incidents reported were matched 1:1 with controls based on sex and type of surgery. Univariable and multivariable analysis were performed to find risk factors associated with airway incident occurrence, and to evaluate influence of airway PSIs on patient prognosis.ResultsAmong 1,038 PSIs voluntarily reported by anesthesiologists during the study period, 281 cases (27.1 %) were airway-related incidents, with an overall reporting incidence of 4.74 per 10,000 among 592,884 anesthesia care episodes. Only ASA physical status was found to be significant independent predictor of these airway PSIs (P = 0.020). Patients with airway PSIs reported had longer extubation time (0.72 ± 1.56 d vs. 0.16 ± 0.77 d, 95%CI: 0.29 to 0.82, P < 0.001), longer ICU length of stay (LOS) (1.63 ± 5.71 d vs. 0.19 ± 0.84 d, 95%CI: 0.57 to 2.32, P = 0.001), longer post operative LOS (10.56 ± 13.09 d vs. 7.59 ± 10.76 d, 95%CI: 0.41 to 5.53, P = 0.023), and longer total in-hospital LOS (14.99 ± 15.18 dra. 11.62 ± 11.88 d, 95%CI: 0.46 to 6.27, P = 0.024).ConclusionsThis single-center retrospective case-control study describes the composition of airway-related PSIs reported by anesthesiologists within thirteen years. Airway incidents might influence patient prognosis by elongating extubation time and LOS. Airway PSI data were worth analyzing to improve patient safety.