sábado, 16 de junio de 2018

Did You Know | AHRQ Patient Safety Network

Did You Know | AHRQ Patient Safety Network

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Did You Know Archive

Order entry errors leading to medication discontinuation in CPOE systems.Order entry errors leading to medication discontinuation in CPOE systems.
Common types of medication errors occurring outside health care settings.Common types of medication errors occurring outside health care settings.
Clinical effects of medication errors occurring in the community.Clinical effects of medication errors occurring in the community.
Handoff communication before and after I-PASS implementation in nursing.Handoff communication before and after I-PASS implementation in nursing.
Types of miscommunication reported by parents and attending physicians.Types of miscommunication reported by parents and attending physicians.
Care processes affected by electronic health record downtime.Care processes affected by electronic health record downtime.
Patient-perceived harm associated with care breakdowns.Patient-perceived harm associated with care breakdowns.
Top 10 patent-reported care breakdowns.Top 10 patent-reported care breakdowns.
Outcomes of referrals on diagnosis.Outcomes of referrals on diagnosis.
Reasons for medication ordering error.Reasons for medication ordering error.
Clinician-provided reason for voiding medication orders.Clinician-provided reason for voiding medication orders.
Medications commonly associated with opioid overdose among young children.Medications commonly associated with opioid overdose among young children.
Adverse drug events associated with overprescribing.Adverse drug events associated with overprescribing.
Drug classes frequently involved in adverse drug events.Drug classes frequently involved in adverse drug events.
Patient impacts of medication errors associated with CPOE.Patient impacts of medication errors associated with CPOE.
Clinicians' recommended solutions for delayed diagnosis in primary care.Clinicians' recommended solutions for delayed diagnosis in primary care.
Clinician-identified problems leading to delayed diagnosis in primary care.Clinician-identified problems leading to delayed diagnosis in primary care.
Patient-identified factors that contributed to adverse events.Patient-identified factors that contributed to adverse events.
Common computerized provider order entry errors.Common computerized provider order entry errors.
Common interruption sources observed among emergency department professionals.Common interruption sources observed among emergency department professionals.
Reasons providers overrode drug allergy alerts in hospital patients.Reasons providers overrode drug allergy alerts in hospital patients.
Communication methods for end-of-rotation handoffs in intensive care units.Communication methods for end-of-rotation handoffs in intensive care units.
Errors associated with preventable deaths after emergency department admission.Errors associated with preventable deaths after emergency department admission.
Patient safety events during medical-surgical hospitalizations for patients with mental illness.Patient safety events during medical-surgical hospitalizations for patients with mental illness.
Source of medication errors during medical-surgical hospitalizations for patients with mental illness.Source of medication errors during medical-surgical hospitalizations for patients with mental illness.
Factors associated with potentially preventable readmissions.Factors associated with potentially preventable readmissions.
Most pediatricians believe medical errors should be disclosed to parents and children.Most pediatricians believe medical errors should be disclosed to parents and children.
Cognitive factors that contribute to diagnostic errors.Cognitive factors that contribute to diagnostic errors.
Hospital-acquired severe sepsis associated with higher hospitalization costs.Hospital-acquired severe sepsis associated with higher hospitalization costs.
System-related factors that contribute to diagnostic errors.System-related factors that contribute to diagnostic errors.
Pediatricians' attitudes toward disclosing errors to pediatric patients.Pediatricians' attitudes toward disclosing errors to pediatric patients.
Patient preferences for end-of-life-care.Patient preferences for end-of-life-care.
Vaccine-related safety incidents among pediatric patients.Vaccine-related safety incidents among pediatric patients.
Reasons for unplanned returns to operating room.Reasons for unplanned returns to operating room.
Given hypothetical scenarios, health care providers in rehabilitation settings classified certain events as more reportable.Given hypothetical scenarios, health care providers in rehabilitation settings classified certain events as more reportable.
Medication groups that trigger drug allergy alerts.Medication groups that trigger drug allergy alerts.
Types of medication incidents affecting pediatric patients.Types of medication incidents affecting pediatric patients.
Consequences of oversight in physical examination.Consequences of oversight in physical examination.
Using checklists during handoffs increased discussions about medications.Using checklists during handoffs increased discussions about medications.
Checklists enhanced information transfer to anesthesiologists.Checklists enhanced information transfer to anesthesiologists.
Key causes of failure to comply with hand hygiene in hospitals.Key causes of failure to comply with hand hygiene in hospitals.
Incidence of omitted information in prescription errors.Incidence of omitted information in prescription errors.
Common reasons for unplanned readmissions following surgery.Common reasons for unplanned readmissions following surgery.
Most e-prescription errors were detected during inputting phase.Most e-prescription errors were detected during inputting phase.
Most pharmacist directors felt that pharmacist interventions influenced appropriate drug use.Most pharmacist directors felt that pharmacist interventions influenced appropriate drug use.
Most medication errors involving older patients occurred between 7–9 AM.Most medication errors involving older patients occurred between 7–9 AM.
Common areas pharmacists provided drug-therapy management services.Common areas pharmacists provided drug-therapy management services.
Factors that contribute to medication errors in older patients.Factors that contribute to medication errors in older patients.
Most liquid dosing errors involve under-dosing.Most liquid dosing errors involve under-dosing.
Barriers to checklist use.Barriers to checklist use.
Most patients who experienced adverse events had only temporary harm.Most patients who experienced adverse events had only temporary harm.
Most high-alert medication errors reached patients but did not cause harm.Most high-alert medication errors reached patients but did not cause harm.
Most primary care malpractice claims related to a problem with diagnosis.Most primary care malpractice claims related to a problem with diagnosis.
Top 5 clinical decision support alerts.Top 5 clinical decision support alerts.
Root causes for suicide attempts on medical-surgical units.Root causes for suicide attempts on medical-surgical units.
Potential adverse drug events related to excessive dosing.Potential adverse drug events related to excessive dosing.
Errors reported in patients receiving radiation therapy.Errors reported in patients receiving radiation therapy.
More doctors than patient care assistants admitted making a mistake in patient care.More doctors than patient care assistants admitted making a mistake in patient care.
The majority of antiretroviral therapy errors were never corrected.The majority of antiretroviral therapy errors were never corrected.
Types of equipment failures in the operating room.Types of equipment failures in the operating room.
Physicians and staff nurses observed concerns on a labor and delivery unit.Physicians and staff nurses observed concerns on a labor and delivery unit.
Information was frequently missing in personal medication lists.Information was frequently missing in personal medication lists.
Physicians reported benefits of EHR system use.Physicians reported benefits of EHR system use.
Most medication incident reports were submitted by nurses.Most medication incident reports were submitted by nurses.
Types of anticoagulant errors in nursing homes.Types of anticoagulant errors in nursing homes.
Top 5 patient-reported elements of missed nursing care.Top 5 patient-reported elements of missed nursing care.
More than half of alarms triggered in an ICU were irrelevant.More than half of alarms triggered in an ICU were irrelevant.
Medication incidents associated with IT systems reported by hospitals.Medication incidents associated with IT systems reported by hospitals.
Implementing bar coding in the ED reduced medication administration errors.Implementing bar coding in the ED reduced medication administration errors.
Types of medication errors occurring in pediatric patients receiving cancer care at homeTypes 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, 2003–2008Comparison of ICU errors reported to the National Reporting and Learning System (NRLS) and MedMarx, 2003–2008
Tactics RNs utilized to prevent near missesTactics RNs utilized to prevent near misses
Most respondents felt in situ simulation helped identify safety threatsMost respondents felt in situ simulation helped identify safety threats
Top 5 communication errors in air medical transportTop 5 communication errors in air medical transport
Parents of children with cancer often used support tools at home for medication use.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.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.A pre- and post-implementation comparison showed that CPOE use reduced potential errors.
Common safe practice violations.Common safe practice violations.
Less than half of pharmacy case manager recommendations were accepted by inpatient physicians.Less than half of pharmacy case manager recommendations were accepted by inpatient physicians.
Many patients did not understand changes to their medications.Many patients did not understand changes to their medications.
Most patient-completed medication reconciliation forms had errors.Most patient-completed medication reconciliation forms had errors.
A prospective standardized incident form increased reporting of complications.A prospective standardized incident form increased reporting of complications.
Top 5 US physician specialties reporting burnout.Top 5 US physician specialties reporting burnout.
Adverse events related to invasive procedures.Adverse events related to invasive procedures.
Top causes for system-based errors.Top causes for system-based errors.
Palliative care providers want more patient safety training.Palliative care providers want more patient safety training.
Residents' ratings of the quality of their education after duty-hour regulations.Residents' ratings of the quality of their education after duty-hour regulations.
Residents themselves feel less prepared for more senior roles following duty-hour regulations.Residents feel less well prepared for senior roles following duty-hours regulations.
Most workflow interruptions in hospitals were by colleagues.Most workflow interruptions in hospitals were by colleagues.
5 contributory factors to safety incidents.5 contributory factors to safety incidents.
Top 5 barriers to physicians seeking support.Top 5 barriers to physicians seeking support.
Top 5 barriers to error disclosure.Top 5 barriers to error disclosure.
Medication errors intercepted by pharmacists.Medication errors intercepted by pharmacists.
The majority of pharmacist-identified errors occurred in the prescribing phase.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.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.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.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.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.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.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.Many patients report their physicians made errors in their care.
Patients who perceive errors in their care often change physicians.Patients who perceive errors in their care often change physicians.
Residents' perceived barriers to potential patient safety solutions.Residents' perceived barriers to potential patient safety solutions.
Most diagnostic errors occurred during the testing phaseMost diagnostic errors occurred during the testing phase
Causes of adverse events in ambulatory diabetesCauses of adverse events in ambulatory diabetes
Most pediatric adverse drug event (ADE)-related visits were in the youngest children.Most pediatric adverse drug event (ADE)-related visits were in the youngest children.
Caregivers who commit errors (Caregivers who commit errors ("second victims") often experience personal problems.
A structured medication administration process decreased errors.A structured medication administration process decreased errors.
Critical care nurses identified 4183 potentially lethal medical errors.Critical care nurses identified 4183 potentially lethal medical errors.
One in three adults misunderstood pediatric medication instructions.One in three adults misunderstood pediatric medication instructions.
Five Drug Types accounted for more than 80% of ED visits for ADEs.Five drug types accounted for more than 80% of ED visits for ADEs.
Classification of drug administration errors in anesthesia malpractice casses.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 notesPhysician attitudes toward copy and paste function (CPF) in electronic notes
Types of wrong-site surgery observed in the previous 6 months by orthopedic surgeonsTypes of wrong-site surgery observed in the previous 6 months by orthopedic surgeons
Location of errors observed by orthopedic surgeons in the previous 6 monthsLocation of errors observed by orthopedic surgeons in the previous 6 months
Types of errors observed by orthopedic surgeons in prior 6 monthsTypes of errors observed by orthopedic surgeons in prior 6 months
Types of errors reported in an academic surgery department in a 12-month periodTypes 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.Of 3522 patients surveyed, 4.2% reported experiencing a harmful adverse event in the past year.
Disruptive behavioursDisruptive 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.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.Many intravenous drug infusions labeled incorrectly.
Most ED cases referred to a physician review committe in an urban hospital ED involved three or more contributing factors.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 errorsFewer 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.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.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.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.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.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 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.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 (Continuity of care 87%, Communication with patients 66%, Overall quality of patient care 60%)Key clinical faculty feel that duty hour regulations have worsened resident patient care
Surgical specimen identification errorsSurgical specimen identification errors
Patient safety publications before and after publication of the IOM report 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. Service quality incident, 52%; No reported incident, 37%; Medical error without risk of harm, 7%; Close call, 2%; Adverse event, 1%. *Numbers do not add to 100 due to rounding.Patients' reports of errors in outpatient chemotherapy via patient safety liaison program
What physicians would disclose about error. Partial disclosure (mention adverse event but not error) -- 56%. Full disclosure (explicit statement that error occurred -- 42%. No disclosure (no reference to adverse event or error) -- 3%.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 disclosedMost physicians think serious and minor errors should be disclosed
More than half of consumers don't have personal set of medical recordsMore than half of consumers don't have personal set of medical records
Categories of missing clinical information during primary care visitsCategories of missing clinical information during primary care visits
Classification of incident reports submitted electronicallyClassification of incident reports submitted electronically
Risk of error almost doubled when nurses worked ≥12.5 consecutive hoursRisk of error almost doubled when nurses worked ≥12.5 consecutive hours
Pie graph showing degree of EHR implementation in all practices. 11.5% -- Fully implemented, 12.7% --Implementation in progress, 14.2 -- Planned in next 12 months, 19.8% -- Planned in next 13-24 months, 41.8% -- Not implemented and no plans in next 24 monthsDegree of EHR implementation in all practices
Table showing Top 5 self-perceived barriers to incident reporting for doctorsTable showing top 5 self-perceived barriers to incident reporting for doctors.
Table showing voluntary reported errorsTable showing voluntarily reported errors.
Table showing Incident Reporting UsageTable showing incident reporting usage.
Table showing Substandard care and frequencyQuality of CPR during in-hospital cardiac arrest is poor
Pie chart 72% Better, 18% Neither better nor worse, 10% WorseNurses’ perceptions of overall medication safety in their hospital since the IOM report
Top seven barriers to implementing patient safety systemsTop seven barriers to implementing patient safety system
Bar graph showing 61% No harm potential, 33% Moderate harm potential, 6% Severe harm potentialMore than half of patients have ≥ 1 unintended medication discrepancy at hospital admission
Bar graph showing 48% Wrong dose, 38% Wrong drug choice, 12% Known drug interaction, 2% otherMost common prescribing errors in long-term care facilities
Bar graph showing 89% checked prescription information, 75% checked for drug allergies, 59% double-checked dosage calculations, 56% checked for renal impairment, 30% checked for potential drug-drug interactionsPercentage of trainees reporting routine use of safe prescribing practices
Pie chart showing that 33% of adverse drug event, 9% of diagnostic error, 13% of other and 45% of technical error in types of Iatrogenic Events Causing Patients to be admitted to ICUTypes of iatrogenic events causing patients to be admitted to ICU
Some hospitals asking patients to remove or cover rubber wristbandsSome hospitals asking patients to remove or cover rubber wristbands
Pie chart showing that 28% of adverse drug events in long term care facilities are serious, life-threatening or fatal. 61% of those serious adverse drug events are preventable.Adverse drug events in long-term care facilities.
Bar graph showing that more than 40% of doctors and nurses surveyed work with people who show poor clinical judgment and have co-workers who repeatedly take shortcuts that could endanger patients.Health care providers rarely confront colleagues on mistakes in patient care.
Bar graph showing that health care facilities attribute medication errors, in decreasing order, to distractions, staffing issues, and workload increases. Health care facilities attribute medication errors to multiple causes.
Bar graph showing that just over 30 percent of physicians and just over 40 percent of the public have reported that they or a family member has been a victim of a medical error. Percentage of physicians and general public reporting that they, or a family member, have been a victim of a medical error.
Pie chart showing that mong 400 consecutive patients at an academic hospital, 76, or 19%, had adverse events soon after discharge, and most were either preventable or ameliorable. Among 400 consecutive patients at an academic hospital, 76 (19%) had adverse events soon after discharge, most either preventable or ameliorable.
Bar graph showing that physicians believe that computerized physician order entry will benefit patient safety more than handheld scanners, whereas nurses believe that handheld scanners will benefit patient safety more. Physicians and nurses disagree on which clinical information technology would benefit patient safety.
Bar graph showing that more than 80% of doctors believe that decision support technology will change medical practice in the next five years, but little more than 5% of doctors are currently using the technology in their own practices. 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.
Bar graph showing that less than 5% of non-English-speaking patients who use a translator do not understand medication instructions, whereas 30% of non-English-speaking patients who do not use a translator do not understand medication instructions. Without interpreter services, non-English speaking patients often don't understand medication instructions.
Pie chart showing that 24% of all errors reported to the Joint Commission on Accreditation of Healthcare Organizations are due to inadequate nurse staffing. Many adverse events attributed to inadequate nurse staffing.
Bar graph showing that less than 5% of urban hospitals surveyed in 2002 currently use Computerized Physician Order Entry, but 30% plan to by 2004. Of urban hospitals surveyed, few currently use computerized physician order entry (CPOE) but 30% plan to by 2004.
Bar graph showing that the probability of a preventable hospital death is greater than that of death by motor vehicle collisionSafety hazards and everyday probabilities.
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