Academic literature on the topic 'Harm-causing errors'

AbstractIntroductionDiagnostic errors cause significant patient harm and increase costs. Data characterising such errors in the paediatric cardiac intensive care population are limited. We sought to understand the perceived frequency and types of diagnostic errors in the paediatric cardiac ICU.MethodsPaediatric cardiac ICU practitioners including attending and trainee physicians, nurse practitioners, physician assistants, and registered nurses at three North American tertiary cardiac centres were surveyed between October 2014 and January 2015.ResultsThe response rate was 46% (N=200). Most respondents (81%) perceived that diagnostic errors harm patients more than five times per year. More than half (65%) reported that errors permanently harm patients, and up to 18% perceived that diagnostic errors contributed to death or severe permanent harm more than five times per year. Medication side effects and psychiatric conditions were thought to be most commonly misdiagnosed. Physician groups also ranked pulmonary overcirculation and viral illness to be commonly misdiagnosed as bacterial illness. Inadequate care coordination, data assessment, and high clinician workload were cited as contributory factors. Delayed diagnostic studies and interventions related to the severity of the patient’s condition were thought to be the most commonly reported process breakdowns. All surveyed groups ranked improving teamwork and feedback pathways as strategies to explore for preventing future diagnostic errors.ConclusionsPaediatric cardiac intensive care practitioners perceive that diagnostic errors causing permanent harm are common and associated more with systematic and process breakdowns than with cognitive limitations.

Medication error is a major cause of morbidity and mortality in medical profession . There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers.Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.Journal of Bangladesh Society of Anaesthesiologists 2014; 27(1): 31-35

Objective: To compare medication errors that reached pediatric and adult patients during hospitalization. Methods: Observational, non-experimental, cross-sectional study from January 2011 to March 2015 at two community-based, teaching hospitals. Results: Over a 4-year period, there were 4.2 and 13.3 million doses dispensed in pediatrics and adults, respectively. Less than 0.25% of doses dispensed contributed to medication errors, with 9.6% of these medication errors reaching patients and 0.04% causing harm. There was no statistical difference in medication error rates based on doses dispensed, patient-days, admission rate, and severity. However, significantly more errors in the documentation and prescribing processes occurred in adults (21.9% vs 6.5% and 37.4% vs 29.8% respectively, p<.001) versus administration in pediatrics (42.5 vs 29.8% in adults, p <0.001). Errors in drug administration that occurred in pediatrics consisted of infusion devices, incorrect dose, the omission of medication, and time of administration. Pediatrics had higher medication errors related to electrolytes and total parenteral nutrition. Independent of age, there were more medication errors that caused harm in patients residing in the intensive care unit (5.5% of 769 vs 3.5% of 2800 patients, respectively, p =0.006). Conclusion: While the prevalence of medication errors that reached patients and caused harm were similar between adults and pediatrics, the types of errors within the medication use process, class of drugs, and severity of the mediation errors varied between the groups. Given these differences, it is quintessential to develop population-specific medication safety programs aimed at addressing the needs of pediatric patients to enhance safe medication use.

AimParenteral nutrition is a high risk treatment, and under- or over-infusion can have serious consequences for patients. Following several errors where parenteral nutrition (PN) was administered at incorrect rates, including incidents of vamin and lipid rates being switched, we aimed to reduce errors causing harm related to PN prescribing and administration.MethodThe local incident reporting system was used to identify errors and trends involving PN. The most common errors involved incorrect rates being either prescribed or administered. A series of interventions were developed between March 2014 and December 2015 aimed at reducing errors.Unit staff were surveyed and PN bag changeover was moved from day to night shifts.The nursing PN administration guideline was updated and relaunched to reinforce the correct procedure.Usual practice on the unit is for nurses to titrate PN to maximum rates according to fluid allowance. Prescription rates were audited, multidisciplinary team (MDT) staff surveyed and daily prescribing of administration rate ranges was implemented with MDT support.PN education sessions were targeted at all staff via a short ‘bootcamp’ format repeated over three weeks and a session at weekly medical teaching. The sessions covered general information, risks and examples of both common and serious errors.ResultsPlanned changes were accepted and supported by the unit staff. The initial prescription audit found 100% of patients had inaccurate rates prescribed and 43% of patients had rates running above those prescribed. Re-audit of prescriptions following the change showed that the correct rate ranges were being updated daily and PN was administered at or below maximum rates. Through the bootcamp sessions we identified some areas of confusion and variations in practice; the administration guideline was further updated as a result. Error monitoring showed an initial increase in reported errors for 2015. These were mainly near miss reports (no harm) but also included two incidents where lipid and vamin rates were switched. This was followed by a reduction in errors in 2016 with no further incidence of lipid and vamin rates switched.ConclusionThe interventions implemented did reduce the incidence of PN errors causing harm. We believe the decrease in errors was due to the cumulative effect of changes and increased awareness. The initial increase in reported errors in 2015 may have been due to increased awareness and reporting. We considered the possibility of interventions increasing errors but discussion with staff involved suggested this was not a factor. MDT involvement is crucial, as is good communication with all staff throughout the change process. We will continue to encourage near miss reporting and monitor on an ongoing basis to ensure the change is sustained, and target new staff to maintain these improvements.

Diagnostic errors can result in tangible harm to patients. Despite our advances in medicine, the mental processes required to make a diagnosis exhibits shortcomings, causing diagnostic errors. Cognitive factors are found to be an important cause of diagnostic errors. With new understanding from psychology and social sciences, clinical medicine is now beginning to appreciate that our clinical reasoning can take the form of analytical reasoning or heuristics. Different factors like cognitive biases and affective influences can also impel unwary clinicians to make diagnostic errors. Various strategies have been proposed to reduce the effect of cognitive biases and affective influences when clinicians make diagnoses; however evidence for the efficacy of these methods is still sparse. This paper aims to introduce the reader to the cognitive aspect of diagnostic errors, in the hope that clinicians can use this knowledge to improve diagnostic accuracy and patient outcomes. Keywords: Affective influence, Analytical, Diagnostic errors, Heuristics, Reflective practice

Abstract: Diagnostic errors causing harm in children are understudied, resulting in a knowledge gap regarding pediatricians’ interest in reducing their incidence.: Electronic survey of general pediatricians focusing on diagnostic error incidence, errors they were interested in trying to improve, and errors reduced by their electronic health record (EHR).: Of 300 contacted pediatricians, 77 (26%) responded, 58 (19%) served ambulatory patients, and 48 (16%) completed the entire questionnaire. Of these 48, 17 (35%) reported making a diagnostic error at least monthly, and 16 (33%) reported making a diagnostic error resulting in an adverse event at least annually. Pediatricians were “most” interested in “trying to improve” missed diagnosis of hypertension (17%), delayed diagnosis due to missed subspecialty referral (15%), and errors associated with delayed follow-up of abnormal laboratory values (13%). Among the 44 pediatricians with an EHR, 16 (36%) said it reduced the likelihood of missing obesity and 14 (32%) said it reduced the likelihood of missing hypertension. Also, 15 (34%) said it helped avoid delays in follow-up of abnormal laboratory values. A third (36%) reported no help in diagnostic error reduction from their EHR.: Pediatricians self-report an appreciable number of diagnostic errors and were most interested in preventing high frequency, non-life-threatening errors. There exists a need to leverage EHRs to support error reduction efforts.

The existence of confusing drug names is one of the most common causes of medication errors. There are many types of medication errors: wrong drug, wrong dose, wrong route of administration, wrong patient etc. Misreading medication names that look similar is a common mistake. These look-alike medication names may also sound alike and can lead to errors associated with verbal prescriptions. Similar sounding drugs may produce confusion and may lead to unintended interchange of drugs causing harm to patients or even patient death. The main aim of the study was to evaluate medication errors related to look alikesound alike drug names and to find out the strategies to prevent these medication errors.J Enam Med Col 2015; 5(2): 110-117

Diagnostic errors are real and are causing harm to patients on a global scale. However, the methods for measuring diagnostic errors are underdeveloped. One very important tool in this regard is the use of autopsies, in order to point out the cases where the actual affliction was missed and to quantify the incidence of such mistakes. We have carried out a study to compare the clinical diagnostic with the post mortem autopsy report in 119 patients who have died at the Pulmonology Hospital in Iasi, Romania, between January 2nd 2016 and January 2nd 2017. The purpose of this research is to determine the incidence of diagnostic errors and to identify the most missed or overlooked respiratory diseases.

Background: Opioid errors are a leading cause of patient harm and adversely impact palliative care inpatients’ pain and symptom management. Yet, the factors contributing to opioid errors in palliative care are poorly understood. Identifying and better understanding the individual and system factors contributing to these errors is required to inform targeted strategies. Objectives: To explore palliative care clinicians’ perceptions of the factors contributing to opioid errors in Australian inpatient palliative care services. Design: A qualitative study using focus groups or semi-structured interviews. Settings: Three specialist palliative care inpatient services in New South Wales, Australia. Participants: Inpatient palliative care clinicians who are involved with, and/or have oversight of, the services’ opioid delivery or quality and safety processes. Methods: Deductive thematic content analysis of the qualitative data. The Yorkshire Contributory Factors Framework was applied to identify error-contributing factors. Findings: A total of 58 clinicians participated in eight focus groups and 20 semi-structured interviews. Nine key error contributory factor domains were identified, including: active failures; task characteristics of opioid preparation; clinician inexperience; sub-optimal skill mix; gaps in support from central functions; the drug preparation environment; and sub-optimal clinical communication. Conclusion: This study identified multiple system-level factors contributing to opioid errors in inpatient palliative care services. Any quality and safety initiatives targeting safe opioid delivery in specialist palliative care services needs to consider the full range of contributing factors, from individual to systems/latent factors, which promote error-causing conditions.

Medication administration is a key skill and it is vital that you are able to demonstrate safety in all aspects of the medication administration process in order to avoid harm or death to your patient. The NMC (2004, 2010) reiterates this point, highlighting that the administration of medicines is an important aspect of a nurse’s professional practice. They argue that it is not simply a mechanistic task, but one that requires thought, exercise and professional judgement. Studies suggest that medicine administration is one of the highest risk processes that a nurse will undertake in clinical practice (NPSA 2007b; Elliot and Lui 2010). Medication administration errors are one of the most common errors reported to the National Patient Safety Agency (NPSA). Indeed in a 12-month period in 2007, 72,482 medication errors were reported with 100 of these causing either death or severe harm to the patient (NPSA 2009). The frequency of these errors has led to a number of changes in the medication administration process. Alongside these important recommendations, most higher education establishments will want to ensure safety of medicine administration and may test this vital skill using an OSCE to ensure that you are adequately prepared for safe administration of medication in practice. There are a number of important laws and key documents that relate to the administration of medication and it is important that you understand these as they all impact upon your practice when administering medication to a patient. You may also be tested on your knowledge in relation to these areas so it is important that you have read these. Important documents you will need to know include: ● The laws that relate to medication in the UK, ● NMC Standards for Medicines Management (2010) (www.nmc-uk.org), ● Local policies related to hospital/Primary Care Trust (PCT) regulation of medication (refer to local guidance). There are a number of laws that influence the manufacturing, prescription, supply, storage and administration of medication. Whilst you will not need to study the intricacies of these laws you will need to understand the main issues each law covers.

This chapter offers an introduction to the recently developed applied health science fields of patient safety, improvement, and implementation sciences. Healthcare is a high-risk activity because of the complexity of its systems and processes. Errors arise frequently and these can impact negatively on patients by causing adverse events. Errors and adverse events are generally attributable to defective systems for organizing care, which create conditions in which errors arise. This represents a failure of risk management. Patient safety science takes a scientific approach to understanding why errors occur and how to prevent their occurrence or minimize their impact. Learning from analysis of patient safety incidents, through root-cause analysis, enables an organization or service to learn and avoid repeating similar failures in the future. Patient safety incidents represent one aspect of the wider problem of poor-quality care. Improvement science offers standardized tools and measurements that can be used to monitor and improve healthcare delivery. The Model for Improvement employs repeated Plan–Do–Study–Act (PDSA) cycles to quantify problems and to develop and test potential solutions. Engagement with stakeholders is an essential part of this process. Implementation science can contribute by providing methods to promote the uptake of new research evidence into healthcare practice. It can address the second translational gap by facilitating the widespread adoption of strategies for improving health-related processes and outcomes, and advancing knowledge on how best to replicate intervention effects from trials into real-world settings. These new scientific fields provide well-established approaches to addressing some of the key problems arising in healthcare. Modern public health needs to reap the benefits of these newly emerged sciences to address the burden of adverse events and harm that arises in the delivery of healthcare and to promote evidence-based practice.

It is well recognized that errors of communication are associated with causing harm to patients on the Intensive Care Unit (ICU). By means of presenting a patient-based narrative, this chapter looks at communication in intensive care medicine focusing attention on styles of communication that are useful in different areas of common practice. It must be accepted that communication needs to convey a message that sits within its own context. For instance, the way that proxy decisions are made for patients who lack capacity varies with both culture and region. Resources are variable, and this includes the time that can be allocated to communication. It is clearly beyond the scope of this chapter to offer guidance on exactly what information should be given to patients and their relatives, but we aim to highlight useful ways of making the communication of that information more effective. 03:00 in a District General Hospital Emergency department. The on-call intensive care doctor is fast-bleeped to the resuscitation bay to see a 35-year-old man called Stephen who has been brought in by ambulance from a roadside accident. He is conscious but distressed, with significant injuries to both legs and thorax. A ‘trauma team’ of doctors is assembled, plus the delivering paramedics, accident and emergency-qualified nurses and healthcare assistants. Communicating with teams in time-critical situations presents a clear challenge. Team members can be unknown to each other with an unknown skill mix, the clinical problems are undefined, different personnel have different—sometimes conflicting—motives, and goals, and clinical priorities can shift over time. The anaesthetist must be confident to communicate with authority in these circumstances. Under stress, most team members will respond well to someone else taking the lead. They will usually do what they are asked if they understand the instruction, are competent to undertake the task, and are not overloaded with other tasks. Closed-loop communication is a good way to keep communication efficient: ‘Someone get me a tube!’ can be misunderstood or ignored by most of the team. ‘Sarah, I want you to get a size 8 endotracheal tube from the trolley and test the cuff for me. Do you know how to do that?’ is specific, directed to a named individual and asks for confirmation of understanding and competence to complete the task.

Objectives. Diagnostic errors are a known patient safety concern across all clinical settings, including the emergency department (ED). We conducted a systematic review to determine the most frequent diseases and clinical presentations associated with diagnostic errors (and resulting harms) in the ED, measure error and harm frequency, as well as assess causal factors. Methods. We searched PubMed®, Cumulative Index to Nursing and Allied Health Literature (CINAHL®), and Embase® from January 2000 through September 2021. We included research studies and targeted grey literature reporting diagnostic errors or misdiagnosis-related harms in EDs in the United States or other developed countries with ED care deemed comparable by a technical expert panel. We applied standard definitions for diagnostic errors, misdiagnosis-related harms (adverse events), and serious harms (permanent disability or death). Preventability was determined by original study authors or differences in harms across groups. Two reviewers independently screened search results for eligibility; serially extracted data regarding common diseases, error/harm rates, and causes/risk factors; and independently assessed risk of bias of included studies. We synthesized results for each question and extrapolated U.S. estimates. We present 95 percent confidence intervals (CIs) or plausible range (PR) bounds, as appropriate. Results. We identified 19,127 citations and included 279 studies. The top 15 clinical conditions associated with serious misdiagnosis-related harms (accounting for 68% [95% CI 66 to 71] of serious harms) were (1) stroke, (2) myocardial infarction, (3) aortic aneurysm and dissection, (4) spinal cord compression and injury, (5) venous thromboembolism, (6/7 – tie) meningitis and encephalitis, (6/7 – tie) sepsis, (8) lung cancer, (9) traumatic brain injury and traumatic intracranial hemorrhage, (10) arterial thromboembolism, (11) spinal and intracranial abscess, (12) cardiac arrhythmia, (13) pneumonia, (14) gastrointestinal perforation and rupture, and (15) intestinal obstruction. Average disease-specific error rates ranged from 1.5 percent (myocardial infarction) to 56 percent (spinal abscess), with additional variation by clinical presentation (e.g., missed stroke average 17%, but 4% for weakness and 40% for dizziness/vertigo). There was also wide, superimposed variation by hospital (e.g., missed myocardial infarction 0% to 29% across hospitals within a single study). An estimated 5.7 percent (95% CI 4.4 to 7.1) of all ED visits had at least one diagnostic error. Estimated preventable adverse event rates were as follows: any harm severity (2.0%, 95% CI 1.0 to 3.6), any serious harms (0.3%, PR 0.1 to 0.7), and deaths (0.2%, PR 0.1 to 0.4). While most disease-specific error rates derived from mainly U.S.-based studies, overall error and harm rates were derived from three prospective studies conducted outside the United States (in Canada, Spain, and Switzerland, with combined n=1,758). If overall rates are generalizable to all U.S. ED visits (130 million, 95% CI 116 to 144), this would translate to 7.4 million (PR 5.1 to 10.2) ED diagnostic errors annually; 2.6 million (PR 1.1 to 5.2) diagnostic adverse events with preventable harms; and 371,000 (PR 142,000 to 909,000) serious misdiagnosis-related harms, including more than 100,000 permanent, high-severity disabilities and 250,000 deaths. Although errors were often multifactorial, 89 percent (95% CI 88 to 90) of diagnostic error malpractice claims involved failures of clinical decision-making or judgment, regardless of the underlying disease present. Key process failures were errors in diagnostic assessment, test ordering, and test interpretation. Most often these were attributed to inadequate knowledge, skills, or reasoning, particularly in “atypical” or otherwise subtle case presentations. Limitations included use of malpractice claims and incident reports for distribution of diseases leading to serious harms, reliance on a small number of non-U.S. studies for overall (disease-agnostic) diagnostic error and harm rates, and methodologic variability across studies in measuring disease-specific rates, determining preventability, and assessing causal factors. Conclusions. Although estimated ED error rates are low (and comparable to those found in other clinical settings), the number of patients potentially impacted is large. Not all diagnostic errors or harms are preventable, but wide variability in diagnostic error rates across diseases, symptoms, and hospitals suggests improvement is possible. With 130 million U.S. ED visits, estimated rates for diagnostic error (5.7%), misdiagnosis-related harms (2.0%), and serious misdiagnosis-related harms (0.3%) could translate to more than 7 million errors, 2.5 million harms, and 350,000 patients suffering potentially preventable permanent disability or death. Over two-thirds of serious harms are attributable to just 15 diseases and linked to cognitive errors, particularly in cases with “atypical” manifestations. Scalable solutions to enhance bedside diagnostic processes are needed, and these should target the most commonly misdiagnosed clinical presentations of key diseases causing serious harms. New studies should confirm overall rates are representative of current U.S.-based ED practice and focus on identified evidence gaps (errors among common diseases with lower-severity harms, pediatric ED errors and harms, dynamic systems factors such as overcrowding, and false positives). Policy changes to consider based on this review include: (1) standardizing measurement and research results reporting to maximize comparability of measures of diagnostic error and misdiagnosis-related harms; (2) creating a National Diagnostic Performance Dashboard to track performance; and (3) using multiple policy levers (e.g., research funding, public accountability, payment reforms) to facilitate the rapid development and deployment of solutions to address this critically important patient safety concern.