AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

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Most liquid dosing errors involve under-dosing. Barriers to checklist use. Most patients who experienced adverse events had only temporary harm. Most high-alert medication errors reached patients but did not cause harm. Most primary care malpractice claims related to a problem with diagnosis. Top 5 clinical decision support alerts. Root causes for suicide attempts on medical-surgical units. Potential adverse drug events related to excessive dosing. Errors reported in patients receiving radiation therapy. More doctors than patient care assistants admitted making a mistake in patient care. The majority of antiretroviral therapy errors were never corrected. Types of equipment failures in the operating room. Physicians and staff nurses observed concerns on a labor and delivery unit. Information was frequently missing in personal medication lists. Physicians reported benefits of EHR system use. Most medication incident reports were submitted by nurses. Types of anticoagulant errors in nursing homes. Top 5 patient-reported elements of missed nursing care. More than half of alarms triggered in an ICU were irrelevant. Medication incidents associated with IT systems reported by hospitals. Implementing bar coding in the ED reduced medication administration errors. Types of medication errors occurring in pediatric patients receiving cancer care at home Comparison of ICU errors reported to the National Reporting and Learning System (NRLS) and MedMarx, 2003–2008 Tactics RNs utilized to prevent near misses Top 5 communication errors in air medical transport Parents of children with cancer often used support tools at home for medication use. Many surgeons felt that managing their own discomfort about poor outcomes was challenging. A pre- and post-implementation comparison showed that CPOE use reduced potential errors. Common safe practice violations. Less than half of pharmacy case manager recommendations were accepted by inpatient physicians. Many patients did not understand changes to their medications. Most patient-completed medication reconciliation forms had errors. A prospective standardized incident form increased reporting of complications. Top 5 US physician specialties reporting burnout. Adverse events related to invasive procedures. Top causes for system-based errors. Palliative care providers want more patient safety training. Residents' ratings of the quality of their education after duty-hour regulations. Residents feel less well prepared for senior roles following duty-hours regulations. Most workflow interruptions in hospitals were by colleagues. 5 contributory factors to safety incidents. Top 5 barriers to physicians seeking support. Top 5 barriers to error disclosure. Medication errors intercepted by pharmacists. The majority of pharmacist-identified errors occurred in the prescribing phase. About half of harmful medication errors in nursing homes occurred during the administration phase. Harmful medication errors in nursing homes occurred nearly twice as often in patients who were unable to direct their own care. Physicians perceive that arrival of new residents has negative impact on care for up to a month. Nurses were felt to be responsible for most of the medication errors in the emergency department. Omitted information is most frequent cause of errors with outpatient computerized prescribing systems. Two-thirds of prescriptions drawn from an electronic health record didn't match the EHR medication list. Many patients report their physicians made errors in their care. Patients who perceive errors in their care often change physicians. Residents' perceived barriers to potential patient safety solutions. Most diagnostic errors occurred during the testing phase Causes of adverse events in ambulatory diabetes Most pediatric adverse drug event (ADE)-related visits were in the youngest children. Caregivers who commit errors ("second victims") often experience personal problems. A structured medication administration process decreased errors. Critical care nurses identified 4183 potentially lethal medical errors. One in three adults misunderstood pediatric medication instructions. Five drug types accounted for more than 80% of ED visits for ADEs. Classification of drug administration errors in anesthesia malpractice cases. Distribution of the 312 "never events" reported to the Minnesota Department of Health in 2007-2008 Physician attitudes toward copy and paste function (CPF) in electronic notes Types of wrong-site surgery observed in the previous 6 months by orthopedic surgeons Location of errors observed by orthopedic surgeons in the previous 6 months Types of errors observed by orthopedic surgeons in prior 6 months Types of errors reported in an academic surgery department in a 12-month period Of 3522 patients surveyed, 4.2% reported experiencing a harmful adverse event in the past year. Disruptive behaviors linked to adverse events in survey* of hospital staff. According to a 2006 study, a quarter of US hospitals have no information technology (IT) applications* for medication safety. Many intravenous drug infusions labeled incorrectly. Most ED cases referred to a physician review committee in an urban hospital ED involved three or more contributing factors. Fewer than 50% of physicians believe they have access to a reporting system in their organization to report medical errors More than 50% of key clinical faculty report worsening medical educational experiences for students on their medicine rotations as a result of duty hour regulations. Surgeons experienced 50% fewer positioning errors with laparoscopic procedure equipment when they used a structured checklist. Sentinel events most frequently reported to The Joint Commission. Most physicians are dissatisfied with current systems to report and disseminate error information in their hospital or health care organization. In a survey of 1082 practicing physicians, most report having been involved in a medical error. Low and marginally literate patients have difficulty following the prescription label instruction "take two tablets by mouth daily" even when they are able to read dosage instructions correctly. Prescribers override more than half of CPOE generated alerts of critical drug-drug interactions (DDIs) without providing a reason. Key clinical faculty feel that duty hour regulations have worsened resident patient care Surgical specimen identification errors Patient safety publications before and after publication of the IOM report "To Err is Human." Patients' reports of errors in outpatient chemotherapy via patient safety liaison program What physicians would disclose about error Frequency of the 154 "never events" reported to the Minnesota Department of Health in 2005-2006 Most physicians think serious and minor errors should be disclosed More than half of consumers don't have personal set of medical records Categories of missing clinical information during primary care visits Classification of incident reports submitted electronically Risk of error almost doubled when nurses worked ≥12.5 consecutive hours Degree of EHR implementation in all practices Table showing top 5 self-perceived barriers to incident reporting for doctors. Table showing voluntarily reported errors. Table showing incident reporting usage. Quality of CPR during in-hospital cardiac arrest is poor Nurses’ perceptions of overall medication safety in their hospital since the IOM report Top seven barriers to implementing patient safety system More than half of patients have ≥ 1 unintended medication discrepancy at hospital admission Most common prescribing errors in long-term care facilities Percentage of trainees reporting routine use of safe prescribing practices Types of iatrogenic events causing patients to be admitted to ICU Some hospitals asking patients to remove or cover rubber wristbands Adverse drug events in long-term care facilities. Health care providers rarely confront colleagues on mistakes in patient care. Health care facilities attribute medication errors to multiple causes. Percentage of physicians and general public reporting that they, or a family member, have been a victim of a medical error. Among 400 consecutive patients at an academic hospital, 76 (19%) had adverse events soon after discharge, most either preventable or ameliorable. Physicians and nurses disagree on which clinical information technology would benefit patient safety. The vast majority of doctors and nurses believe that decision support technology will change medical practice in the next 5 years, but few actually use it now. Without interpreter services, non-English speaking patients often don't understand medication instructions. Many adverse events attributed to inadequate nurse staffing. Of urban hospitals surveyed, few currently use computerized physician order entry (CPOE) but 30% plan to by 2004. Safety hazards and everyday probabilities.