Intensive care unit errors: detection and reporting to improve outcomes

Most efforts to identify and investigate errors in medicine have focused on active failures and general provider behaviors. We believe that the greatest improvements in error identification and management in the intensive care unit will be achieved by focusing on the intensive care unit's organizational characteristics. The results of three recent studies suggest that differences in intensive care unit organizational characteristics are significantly related to variation in the risk-adjusted morbidity and mortality. Physicians must assume greater leadership in creation of these safe systems for intensive care patients. We encourage the creation of multi-institutional communities to work collaboratively to advance patient safety in high-risk environments like the intensive care unit.     

Inconsistent reporting of minimally invasive surgery errors

Introduction

Minimally invasive surgery (MIS) is a complex task requiring dexterity and high level cognitive function. Unlike surgical ‘never events’, potentially important (and frequent) manual or cognitive slips (‘technical errors’) are underresearched. Little is known about the occurrence of routine errors in MIS, their relationship to patient outcome, and whether they are reported accurately and/or consistently.

Methods

An electronic survey was sent to all members of the Association of Surgeons of Great Britain and Ireland, gathering demographic information, experience and reporting of MIS errors, and a rating of factors affecting error prevalence.

Results

Of 249 responses, 203 completed more than 80% of the questions regarding the surgery they had performed in the preceding 12 months. Of these, 47% reported a significant error in their own performance and 75% were aware of a colleague experiencing error. Technical skill, knowledge, situational awareness and decision making were all identified as particularly important for avoiding errors in MIS. Reporting of errors was variable: 15% did not necessarily report an intraoperative error to a patient while 50% did not consistently report at an institutional level. Critically, 12% of surgeons were unaware of the procedure for reporting a technical error and 59% felt guidance is needed. Overall, 40% believed a confidential reporting system would increase their likelihood of reporting an error.

Conclusion

These data indicate inconsistent reporting of operative errors, and highlight the need to better understand how and why technical errors occur in MIS. A confidential ‘no blame’ reporting system might help improve patient outcomes and avoid a closed culture that can undermine public confidence.     

Influences observed on incidence and reporting of medication errors in anesthesia

Background

Medication errors are a common occurrence during the conduct of anesthesia (one in 113-450 patients). Several factors contribute to medication errors in anesthesia, including experience of the anesthesia provider, severity of comorbidities, and type of procedure. The inexperience of anesthesia providers-in-training also leads to increased error rates. This prospective observational study repeats and extends previous work by Webster et al. and Llewellyn et al. examining the role of comorbidities, type of case, and level of provider experience on the incidence of medication errors.

Methods

After Institutional Review Board review and exemption from informed consent, medication error reporting forms were attached to every anesthetic record during a six-month period. All providers were asked to return the forms for every anesthetic, on a strictly voluntary and anonymous basis, and to record the occurrence of medication errors. If providers indicated that a medication error had occurred, additional details about the event were obtained anonymously.

Results

There were 8,777 (83%) responses obtained in a review of 10,574 case forms. A medication error was reported in 35 forms, with an additional 17 forms indicating a medication pre-error or near miss, resulting in 52 (0.49%) errors/pre-errors or a reported incidence of 1:203 anesthetics. Most case types were observed to have a statistically significant increase in reported medication errors. Reported errors by type of anesthesia provider were categorized into anesthesia provider-in-training group and the experienced provider group. The anesthesia provider-in-training group reported a twofold increase in the rate of errors, with the most frequently reported errors being incorrect dose and substitution.

Conclusion

This study suggests that case type, American Society of Anesthesiologists?? classification, and level of provider experience play a role on the rate of medication errors. The results of this study are in agreement with previously reported error rates.     

Considerations in treatment integrity: implications and recommendations for PTSD research

In this article, the authors address the rationale for and uses of treatment integrity measurement in psychotherapy research, focusing on therapists' adherence and competence in trauma and posttraumatic stress disorder treatment research. The following issues are examined: (a) distinctions between adherence monitoring, performed contemporaneously with ongoing study treatments, and adherence evaluation, and the implications for outcomes analysis; (b) simultaneous measurement of adherence and competence; (c) selection of sessions for adherence/competence assessment and the need for concurrent outcome measurement, and (d) the association between therapist adherence, competence, alliance and treatment outcome. Recommendations regarding common problems in the implementation of adherence and competence measurement are made throughout. The article concludes with a summary of steps and considerations in decision-making with regard to treatment integrity.     

How a system for reporting medical errors can and cannot improve patient safety

The Institute of Medicine has recommended systems for reporting medical errors. This article discusses the necessary components of patient safety databases, steps for implementing patient safety reporting systems, what systems can do, what they cannot do, and motivations for physician participation. An ideal system captures adverse events, when care harms patients, and near misses, when errors occur without any harm. Near misses signal system weaknesses and, because harm did not occur, may provide insight into solutions. With an integrated system, medical errors can be linked to patient and team characteristics. Confidentiality and ease of use are important incentives in reporting. Confidentiality is preferred to anonymity to allow follow-up. Analysis and feedback are critical. Reporting systems need to be linked to organizational leaders who can act on the conclusions of reports. The use of statistics is limited by the absence of reliable numerators and denominators. Solutions should focus on changing the cultural environment. Patient safety reporting systems can help bring to light, monitor, and correct systems of care that produces medical errors. They are useful components of the patient safety and quality improvement initiatives of healthcare systems and they warrant involvement by physicians.     

护理研究生学术道德与负责任研究行为的培养

分析了研究生学术道德现状及影响因素,概述了负责任研究行为的相关内容,并提出有效培养护理专业研究生负责任研究行为的措施,以提高护理研究生的学术道德与科研诚信。     

给药错误事件根因类型信息指标的确定与电子上报系统设计

目的确定给药错误事件电子上报系统的根因类型信息项,以实现事件根因类型分析的结构化、自动化。方法参考根因分析理论框架,研究小组初步拟定给药错误事件根因类型信息项并形成函询问卷,以德尔菲法确定给药错误事件根因类型结构化信息内容,由软件工程师根据上报表模块设计需求,开发给药错误事件根因分析结构化电子上报系统。结果给药错误事件电子上报表根因类型结构化信息内容有激发问题(一级指标)18项,提示答案(二级指标)84项;开发的电子上报系统有上报模块和报表模块,报表模块有查询和分析功能。结论确定的根因类型信息涵盖了质量管理的主要因素,上报系统能帮助护理管理者快速、有效地查寻给药错误事件的根本原因,并根据高发原因采取针对性管理措施,提高管理效率及效能。     

Adherence to standardization and integrity in translational medicine research

Throughout history, the progress of human society has been propelled by continuous accumulation of experience. People distill patterns and rules out of their experience that contribute to broader applicability. This is how preliminary theories are formulated.