Admission handoff communications: clinician’s shared understanding of patient severity of…

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Physicians’ attitudes toward reporting medical errors-an observational study at a general…

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Medicines reconciliation using a shared electronic health care record.
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Are sequential compression devices commonly associated with in-hospital falls? A myth-busters review using the patient safety net database.
J Patient Saf. 2011 Jun;7(2):77-9
Authors: Boelig MM, Streiff MB, Hobson DB, Kraus PS,…

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Related Articles

Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study.

J Patient Saf. 2009 Mar;5(1):16-22

Authors: Benkirane RR, R-Abouqal R, Haimeur CC, S Ech Cherif El Kettani SS, Azzouzi AA, M’daghri Alaoui AA, Thimou AA, Nejmi MM, Maazouzi WW, Madani NN, R-Edwards I, Soulaymani RR

BACKGROUND: In recent years, medication error has received considerable attention because it causes substantial mortality, morbidity, and additional health care costs. Collecting information in this field depends on the willingness of health professionals to report their errors. Another important point is to identify patients at high risk for an adverse drug event (ADE) to oversee the quality of the entire drug distribution chain, including prescription, drug choice, dispensing, and preparation to the administration of drugs. OBJECTIVE: To assess the prevalence rate of ADEs. To ascertain those related to medication errors to develop prevention strategies. DESIGN: Prospective cohort study. SETTING: Multicenter study, 7 intensive care unit in academic and military hospital of Rabat. PERIOD: Three months. PATIENTS: Adult and pediatric patients in medical/surgical intensive care units. COLLECTION DATA: One coordinator for each participating ward collaborates with a pharmacist investigator from Moroccan pharmacovigilance center in the detection of ADEs. MEASUREMENTS AND MAIN RESULTS: Of the 696 patients studied, the investigators identified 108 incidents (15.5 %) (95% confidence interval, 14.1-16.9). The reviewers concluded that 56 (70%) of 80 ADEs were nonpreventable, which, by definition, are considered as ADRs. Among the 52 medication errors, 28 (53.8%) led to potential ADEs and 24 (46.2%) led to actual preventable ADEs. There were 7.7 medication errors for 1000 patient-days. We noted that the preventable ADEs occurred in the prescribing (71.1%), administration (21.2%), transcription (5.7%), and dispensing stages. Errors of wrong or improper drug use accounted for the majority of potential and actual preventable ADEs (23%), followed by improper dose (21.1%), wrong duration of treatment (19.2%),wrong rate of administration(13.5), errors due to drug omission (9.6%), wrong administration technique (5.8%), wrong dosage form (3.8%), and wrong administration timing (1.9%). CONCLUSIONS: This study argues the need for pharmacovigilance to extend its scope to medication errors to improve the safety of drugs. Our results underlined that medication errors are likely to be more serious than ADRs. Our approach based on the collaboration between the pharmacovigilance center and clinicians can be a powerful tool for incorporating error reporting into the culture of medicine.

PMID: 19920434 [PubMed - indexed for MEDLINE]

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Hospitalists as Emerging Leaders in Patient Safety: Lessons Learned and Future Directions.

J Patient Saf. 2009 Mar;5(1):3-8

Authors: Flanders SA, Kaufman SR, Saint S, Parekh VI

OBJECTIVE:: To examine the results of a multi-institution, hospitalist-centered consortium designed to disseminate knowledge of best practices relevant to patient safety and to facilitate institutional innovation around such practices. METHODS:: The Hospitalists as Emerging Leaders in Patient Safety (HELPS) consortium consisted of a hospitalist lead and a patient safety representative from each of 9 health care systems in southeastern Michigan. The consortium’s aim was to provide rapid dissemination of best practices in patient safety through regular group meetings and to facilitate implementation and analysis of hospitalist-led patient safety initiatives. Key safety targets included prevention of device-related infections, creating a culture of safety, care transitions, medication safety, fall prevention, perioperative care, intensive care unit safety, and end-of-life care. Participating institutions were free to implement any of the best practices and had access to the expertise of the HELPS coordinating site. Surveys were used to assess knowledge dissemination among participants. RESULTS:: Participating institutions described their patient safety initiative and identified several key barriers and facilitators encountered during implementation. Common themes emerged among both barriers and facilitators. In postmeeting surveys to measure dissemination, consortium participants answered a mean of 84.2% (SD = 19.2) of the questions correctly. CONCLUSIONS:: The HELPS consortium successfully disseminated knowledge regarding best practices and identified common barriers and facilitators faced by hospitalists and institutions attempting to improve safety. The next step is to transform the consortium into a robust quality collaborative that leverages key facilitators and prospectively addresses barriers to implementing high-impact interventions in a multihospital setting.

PMID: 19920432 [PubMed - as supplied by publisher]

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