Vaccine administration error rates at a large academic medical center and its affiliated clinics – Familiarity matters

ObjectiveThe purpose of this study was to track and describe the absolute number of vaccine administration errors and corresponding error rates over time and by patient age and vaccine type.MethodsTotal vaccines administered to patients aged 0 through 19 years 364 days from 1/1/2006 through 12/31/2017 at a large academic health system in the Midwest United States with primary, specialty and school-based clinics, and a pediatric hospital were obtained from an electronic medical record. Vaccine administration errors over the same time period for the same patient criteria were analyzed from the health system’s incident reporting system and further compared to the frequency of all incidents reported. Vaccine administration error rates were calculated. Data were analyzed by patient age, vaccine type and year administered.ResultsOf the 1,431,206 vaccine doses given, 552 vaccine administration errors were identified (0.04%). The highest error rates occurred in children aged 2, 3, and 19 years. Vaccine types with the highest error rate were Td, rabies and pneumococcal polysaccharide vaccines. Overall vaccine doses given and errors reported increased over the study period. However, the increase was disproportionate, resulting in an increase in the error rate initially followed by a stabilization at the end of the study period.ConclusionsVaccine administration errors are uncommon. The error rate appears to be stabilizing. Errors are more likely at ages when vaccines are not commonly given, with vaccines that have age-specific dosing and with vaccines that are given less often. This suggests more safety checks are needed for vaccines that are rarely used or given off-schedule, and manufacturers should avoid vaccines with age-specific dosing.     

1例自备药用药错误的分析与改进

针对1例自备药用药错误事件进行分析,并制定改进措施。通过完善自备药管理制度,规范自备药使用流程,创建学习型科室,提高了医护人员用药安全意识及合理用药水平,杜绝了自备药用药错误再次发生     

A New Method to Guard Inpatient Medication Safety by the Implementation of RFID

Since life is invaluable, the patient safety is always an important issue. How to reduce the malpractices and advance the patient safety is the primary goal of many countries. The current problem is that the hospitals cannot quickly and precisely identify the name of medicine, the position of patient and staff and the servicing time and dosage taken by patients. The application of Radio Frequency Identification (RFID) is rocketing in popularity as varieties of expanded uses. However, due to the investment consideration, there are few cases that practically implement such a technology in healthcare industries. This paper presents a Wisely Aware RFID Dosage (WARD) system, which based on an integration of barcodes and RFID tags, to demonstrate effective and safe patient care environment, for preventing the risk of medication error. Finally, through an evaluation of users’ satisfaction, a reliability of 0.92 and a criterion-related validity of 0.82 show that this system is able to effectively construct the patient-safety-centric environment.     

酷似流行性出血热的伤寒(附3例报告)

本例分析3例伤寒患者,初因有“三红”(面、颈、前胸充血潮红)、血小板减少、蛋白尿而误诊为流行性出血热。说明“三红”等并非流行性出血热所特有,非典型伤寒也可出现,故诊断前应细致检查综合分析。尤其对酷似流行性出血热伴有热程长、肝脾肿大、白血球减少的患者,应考虑到伤寒。     

26例肺炎性假瘤的误诊和治疗分析

本文报告26例肺炎性假瘤的误该和治疗,指出近年本病发病率有增高趋势,男性40岁以上病人明显增加。其临床症状、X线表现酷似肺癌。对其特点认识不足,病理检查亦往往有误。术前检查及观察不够充分、仓促手术为误诊的重要原因。本文提出了避免误诊和防止手术范围扩大的几点意见。     

Preventing Wrong Tooth Extraction

Objective of WorkWrong-site tooth extraction (WSTE) is the most common serious patient safety incident in dentistry. Safety checklists have significantly reduced wrong-site surgery, although their benefit is unproven in primary care dentistry. Our quality improvement project developed and implemented a checklist optimised for oral surgery procedures in primary care to reduce WSTE risk.Material and MethodsLocal best practice for tooth extraction record-keeping (LBP), using national guidelines and standards was devised. We then retrospectively audited tooth extraction record-keeping against LBP. Deficiencies in current record-keeping practice were identified and used to design a checklist aimed at improving compliance. We provided a computerised safety checklist compliant with LBP to eleven clinicians at three general dental clinics within our region. The checklist included a pre-operative safety check, a pause to re-confirm the surgical site and a post-operative record-keeping proforma. The checklist was linked to our record-keeping software for use during tooth extraction. We audited checklist completion and compliance with LBP fortnightly for ten weeks.ResultsThe introduction of a safety checklist resulted in increased compliance with LBP for tooth extraction record keeping. At week ten, 67% of records contained the computerised safety checklist. This resulted in a 50% increase in overall compliance with LBP for tooth extraction compared to baseline.ConclusionsA computerised safety checklist for tooth extraction in primary care has potential to improve patient safety by adopting measures to prevent WSTE and standardising communication between clinicians. Checklists in general practice should be encouraged.     

On measurements and their quality: Paper 3: Post hoc pooling and errors of discreteness

This is the third in a short series of papers on measurement theory and practice with particular relevance to research in nursing, midwifery, and healthcare. In this paper I demonstrate how the decisions we make regarding the post hoc treatment of our measurements impact the quality of our data and influence the validity of the inferences we draw from them. I address two variations of this practice, pooling data over response options found on self-report measures, and transforming measurements of continuous variables, such as age, into ranges or ordered categories. The problems inherent in this practice are examined using concepts from information theory. Pooling more precise measurements into less precise ones creates errors of discreteness that introduce unpredictable (positive or negative) bias in our results.     

晶状体脱位继发急性闭角型青光眼误诊分析

目的:分析晶状体脱位继发急性闭角型青光眼的临床特点及误诊原因。方法:对晶状体脱位继发急性闭角型青光眼患者36例(41只眼),采用房角镜和(或)超声生物显微镜(UBM)检查,根据其临床特点,选择适当的手术治疗。结果:41只眼中31只眼(75.61%)误诊为原发性急性闭角型青光眼。单眼晶状体脱位继发急性闭角型青光眼的前房深度较对侧眼明显变浅,差异有统计学意义(P<0.05)。术后1个月,患者视力不同程度提高;眼压正常。结论:晶状体脱位继发急性闭角型青光眼容易误诊为原发性急性闭角型青光眼,误诊原因主要为病史询问不清、眼部检查不仔细。治疗晶状体脱位继发急性闭角型青光眼,需要解除晶状体因素,才能提高手术成功率。     

Risk-taking decisions in pathological gamblers is not a result of their impaired inhibition ability

This work investigates whether inhibition impairments influence the decision making process in pathological gamblers (PGs). The PG (N = 51) subjects performed the Iowa Gambling Task (IGT as the measure of the decision making process) and two tests of inhibition: the Stroop (interference inhibition), and the Go/NoGo (response inhibition), and were compared with demographically matched healthy subjects (N = 57). Performance in the IGT block 1 and block 2 did not differ between the groups, but the differences between the PGs and healthy controls began to be significant in block 3, block 4 and block 5. PGs learned the IGT task more slowly than the healthy controls and had non-optimal outcomes (more disadvantageous choices). Impaired IGT performance in PGs was not related to an inhibition ability measured by the Stroop (interference response time) and the Go/NoGo (number of commission errors) parameters. Further controlled studies with neuroimaging techniques may help to clarify the particular brain mechanisms underlying the impaired decision making process in PGs.     

儿童屈光不正性弱视的疗效观察

目的探讨儿童屈光不正性弱视的临床疗效及预后。方法排除器质性眼病和病理性斜视,对105例屈光不正性弱视儿童进行散瞳、验光、配镜、遮盖及精细目力训练等。结果本组年龄越小治愈率越高,弱视程度越轻治疗效果越好,弱视的性质不同疗效亦不同,屈光参差性弱视疗效最差,重度性弱视几乎无治愈。结论儿童在视觉发育期屈光不正性弱视预后较好。关键在于早期发现,及时和正确治疗,绝大多数视力可提高,一部分可获得正常视力。