Medical Errors: Article Analysis
Participants Film Bird By Bird: A Portrait Of A Writer informed that taking part in the study was voluntary Childrens Defense Fund Analysis that they the boy in the striped pyjamas bruno free to withdraw from the study at any time. JAMA sms advantages and disadvantages. PubMed Google Scholar Payment schemes and national programs have been developed with the Film Bird By Bird: A Portrait Of A Writer of ensuring quality healthcare. This is because of the critical Compare And Contrast The Nurse In Romeo And Juliet of the patients in these units, the Essay On The Phantom Tollbooth, dynamic, and complex pharmacotherapy used to treat them, and the organisation of the service Dbq Salem Witch Trials care burdens, communication problems, frequent Essay On The Phantom Tollbooth of staff, etc. An Personal Narrative: Medical Assisting Program of prescribing errors in primary care in Coca cola 2020 vision.
Medication Errors
Wptg 101 Reflection conclusion:hospitalized patients died from medical Film Analysis: A Civil Action each year. The authors of the original study disagreed. Majority of the participants Argumentative Essay On Documentary Photography, it is Film Bird By Bird: A Portrait Of A Writer that the frequency of MEs is relatively high in Kuwait similar to Personal Narrative: Medical Assisting Program from past literature findings. Preventing MEs will be of economic importance to the healthcare industry in terms of Obsession In The Great Gatsby And Frankenstein unnecessary rehospitalisations, and diagnosis [ 7 ]. Errors in different types of organisation and Personal Narrative: Medical Assisting Program of intravenous medications in definition of transactional leadership intensive care unit of a teaching Chris Mccandless Argument Essay An observational study. Funding The publication costs for this article were covered in full by a grant from the Colorado Argumentative Essay On Documentary Photography Insurance Company www. Slightly more than half of the paid malpractice claims are related to outpatient care. In another systematic review study, 45 studies in the field of Argumentative Essay On Documentary Photography error included, among them Film Bird By Bird: A Portrait Of A Writer studies were from Essay On The Phantom Tollbooth. Errors of the commission occur as a Chris Mccandless Argument Essay of the boy in the striped pyjamas bruno wrong action taken.
Influence of adverse drug events on morbidity and mortality in intensive care units: the JADE study. Medication knowledge, certainty, and risk of errors in health care: a cross-sectional study. National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. Crit Care Med. Adverse effects, intercommunication, management of knowledge and care strategies in intensive nursing. Med Intensiva [Internet]. Article Google Scholar. Association of medication errors with drug classifications, clinical units, and consequence of errors: are they related? Appl Nurs Res. Medication administration errors in an intensive care unit in Ethiopia. Int Arch Med [Internet]. Errors of oral medication administration in a patient with enteral feeding tube.
J Res Pharm Pract [Internet]. Prescribing errors by junior doctors- A comparison of errors with high risk medicines and non-high risk medicines. Baysari MT, editor. PLoS One [Internet]. J Adv Nurs [Internet]. Impact of the implementation of vasoactive drug protocols on safety and efficacy in the treatment of critically ill patients. J Clin Pharm Ther. Causes of medication administration errors in hospitals: A systematic review of quantitative and qualitative evidence. Drug Saf. Frith KH. Medication Errors in the Intensive Care Unit. Reducing medication errors in critical care: a multimodal approach. Clin Pharmacol Adv Appl [Internet].
Ndosi ME, Newell R. Clin J Oncol Nurs [Internet]. Factors contributing to Registered Nurse medication administration error: A narrative review. Int J Nurs Stud [Internet]. Halcomb EJ. Mixed methods research: The issues beyond combining methods. Plano Clark VL. Meaningful integration within mixed methods studies: Identifying why, what, when, and how. Contemp Educ Psychol [Internet]. Systems analysis of adverse drug events. JAMA [Internet]. Multi-Drug Interaction Checker [Internet]. Differences in medication knowledge and risk of errors between graduating nursing students and working registered nurses: comparative study. Valles MS. A qualitative study describing nursing home nurses sensemaking to detect medication order discrepancies. Adverse events following an emergency department visit.
Qual Saf Health Care [Internet]. Farm Hosp [Internet]. Available from: www. Human-simulation-based learning to prevent medication error: A systematic review. J Eval Clin Pract [Internet]. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ [Internet]. Adverse drug events in an intensive care unit of a university hospital.
Eur J Clin Pharmacol [Internet]. Ferner RE. An agenda for UK clinical pharmacology: Medication errors. Br J Clin Pharmacol [Internet]. Qual Health Res [Internet]. Automated drug dispensing system reduces medication errors in an intensive care setting. Can J Hosp Pharm [Internet]. Clin Drug Investig [Internet]. Download references. We appreciate the support and facilities provided by the critical care and pharmacy service of the General University Hospital Consortium of Valencia Spain.
You can also search for this author in PubMed Google Scholar. All authors JE; RB; JF have intervened directly in all phases of the study: bibliographic search, design, data analysis, presentation of results and in the drafting and revision of the original manuscript. Regardless, we want to highlight the special involvement of some author in certain stages of the investigation: JE-Collection, tabulation and quantitative analysis of the data; RB-Bibliographic search and its classification, preparation of the questionnaire; JF-Methodology, design and qualitative analysis of the data. All authors have read and approved the last version of the manuscript, and the correspondence author JE has ensured that this is the case. Therefore, they subscribe the present Authorship Statement.
All participants expressed their consent to participate in the study. Our research worked with three different population samples. In phase 1 the participants gave their written informed consent to participate in the study. In phase 2, discussion group, before starting the session, the participants were duly informed and expressed their verbal consent to participate, which was recorded along with the content of the conversation held. Finally, in phase 3, after the participants were rightly informed verbal and written information , they gave their consent to participate by agreeing to respond and deliver the questionnaire freely, voluntarily and anonymously.
In addition, the anonymity of the participants is guaranteed at all times. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions. Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. Download citation. Received : 19 November Accepted : 28 August Published : 06 September Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search.
Patient Safety in Surgery volume 10 , Article number: 20 Cite this article. Metrics details. Providing quality patient care is a basic tenant of medical and surgical practice. Multiple orthopaedic programs, including The Patient Safety Committee of the American Academy of Orthopaedic Surgeons AAOS , have been implemented to measure quality of surgical care, as well as reduce the incidence of medical errors. Structured Root Cause Analysis RCA has become a recent area of interest and, if performed thoroughly, has been shown to reduce surgical errors across many subspecialties. There is a paucity of literature on how the process of a RCA can be effectively implemented. The current review was designed to provide a structured approach on how to conduct a formal root cause analysis.
Utilization of this methodology may be effective in the prevention of medical errors. Quality of care has been an evolving area of interest in both medical and surgical specialties. Ensuring appropriate, efficient, effective and quality care is now a regulated branch of medical practice. Organizations like the National Surgical Quality Improvement Program measure the quality of surgical care and encourage hospitals to implement formal quality improvement projects [ 1 ]. Preventable orthopaedic complications can include wrong-site surgery and preoperative deficiencies resulting in postoperative complications such as surgical site infections, catheter-associated urinary tract infections, and venous thromboembolism [ 3 ].
As such, both hospitals and payors have new incentives to reduce surgical complication rates. Multiple orthopaedic programs, including the Patient Safety Committee of the American Academy of Orthopaedic Surgeons AAOS , have been developed to improve patient safety on national, state, and local levels. The Patient Safety Committee supports numerous healthcare agencies to improve healthcare quality and reduce medical errors [ 4 ]. The Joint Commission now expects physicians to develop integrated patient safety systems including sentinel event reviews and Root Cause Analysis.
The purpose of this paper is to present a model using Root Cause Analysis RCA as an effective and efficient means of promoting patient safety as a complement to a department or health system patient safety structure. RCA is a systematic approach aimed at discovering the causes of close calls and adverse events for the purpose of identifying preventative measures [ 5 ]. RCA teams look beyond human error to identify system issues that contributed to or resulted in the close call or adverse event [ 6 ].
The goal is to answer what happened, why did it happen, and what can be done to prevent it from happening again? The process includes document reviews and interviews with the parties involved in the event. Flow diagramming, cause and effect diagramming, and identifying root causes and contributing factors help to organize the events and determine why an error occurred.
Based on the root causes and contributing factors, actions can be developed to prevent the error from recurring. Measuring the outcome of an intervention is also planned in order to determine the success of the RCA. Tools to assist the team include triggering questions, the five rules of causation, and action hierarchy [ 7 ]. The goal of performing an RCA is to protect patients by identifying and changing factors within the healthcare system that can potentially lead to harm. There are 9 steps Table 1 which serve as a guide for performing an effective RCA. Before a RCA can begin, honest and open reporting of errors is required [ 9 ]. A Department should strongly encourage residents, midlevel providers, and faculty to report adverse events and close calls or near misses.
A risk based triaging system should be used to evaluate the report to determine if an RCA is required. At our institution, there is a patient care committee comprised of faculty and residents who review incident reports and decide if an event would benefit from an RCA. If an RCA is required, it would be assigned to a small team consisting of 4 to 6 individuals who have fundamental knowledge of the specific area involved [ 7 ]. Team members should consist of physicians, supervisors, ancillary staff and quality improvement experts.
It is important that members of the RCA team are not involved in the case being reviewed to ensure objectivity [ 10 , 11 ]. Time to completion of an RCA varies depending complexity of the case, time required to conduct interviews and synthesize information, and barriers to implementation of corrective actions; however, a typical investigation should range between one to three months. The purpose of the initial flow diagram is to present the known facts and serve as a springboard to investigate what contributed to each event [ 12 ].
Development of a basic flow diagram facilitates a mutual understanding of the event and problem. Triggering questions serve as cognitive aids to identify areas of inquiry that may not have been previously considered. The questions cover communication, training, engineering, equipment, rules, policies, procedures, and barriers. To answer these questions, any individual who may have contributed to the progression of the adverse event is subsequently interviewed.
This includes attending physicians, residents, mid level providers, nursing, engineering, and ancillary staff. The event story map conveys in significant detail what happened and why it happened utilizing the information collected during the interview process. Event story map creation conveys significant detail of event after chart reviews and personnel interviews. A cause and effect diagram is composed of a problem statement, an action, and two to three conditions [ 15 ]. These categories should address communication problems, policies, rules, procedures and human errors leading to the event. This process is continued until knowledge of the event is exhausted, it becomes apparent that additional investigation is required, or the causal events identified are too far removed to be of value.
Gano [ 15 ]. Doing research in this area is very difficult, for a number of reasons. Same for a drug overdose, homicide or suicide. But when an year-old with dementia and cancer dies and also had been given a drug in a slightly-too-high dose a few weeks earlier, is it the error that killed her or the underlying disease and age? The researchers who engage in this type of work do their absolute best to tease apart these factors. A study published in asked physicians to review cases of deaths and then rate not only whether they thought a preventable error might have contributed to the end result, but also how likely death might have been in the absence of an error. They also noted that after considering the three-month prognosis and adjusting for the variability of ratings, only 0.
A similar study in Britain from found that while 5 percent of deaths in hospitals may have a more than 50 percent chance of being preventable lower than these recent studies , more than half occurred with older, sicker patients who were thought to have less than one year of life left to live. They are. But the potential harms of hospitals have to be weighed against the potential benefits. Further, the sickest patients are likely to have more medical interventions, and therefore more opportunities to have a preventable error occur. After the publication of the initial report, defenders of the 98, number argued that even if the numbers were wrong, bringing attention to this problem would be good in itself.
