Causes Of Medication Errors Research Articles

Disparities in patient-resident physician communication and counseling: A multi-perspective exploratory qualitative study.

Effective communication between physicians and patients plays an integral role in clinical care. Gaps in a physician's ability to ensure effective communication, especially with patients from diverse backgrounds, are known causes of medical errors. This study explores the potential biases and disparities in patient-resident communication, which may influence a patient's quality of care. This exploratory qualitative study was conducted at the largest academic medical center in Pakistan. Purposive sampling was used to approach participants from surgery, medicine, obstetrics and gynecology, pediatrics and family medicine. Faculty, fellows and residents working in these departments and medical students in their fourth and fifth years of undergraduate education with prior experience of at least one month in these specialties during their clinical rotations were included. Focus group discussions (FGDs) lasting 45-60 minutes were conducted with each cohort of healthcare professionals separately, using a semi-structured interview guide. Sixty participants (19 males and 41 females, mean age: 32.9, SD: 10.9) took part in the study. Thematic analysis revealed five major themes. Four themes focused on residents' biases and patient disparities hindering patient-resident communication: (1) patient-resident gender discordance (2) ethnicity and language barriers, (3) differing social class of the patient, and (4) challenging patient-resident interactions (patients resistant to treatment, exceedingly inquisitive and those with multiple attendants, etc.). The fifth theme identified the need for a communication skills curriculum in postgraduate medical education. Opposite gender and discordant socioeconomic/cultural backgrounds of patients pose a challenge to effective patient-physician communication. Self-identification and awareness of residents' biases when interacting with patients can ensure their active elimination and improve their communication skills. Integrating these components in a standardized curriculum within postgraduate programs can enable resident-physicians to provide the same level of care and communicate more efficiently with patients of all backgrounds.

Investigating Causes of Medical Errors in Intensive Care Units in Iran: A Cross-sectional Study.

Medical errors cause disability and mortality in intensive care units (ICUs). We aimed to determine the occurrence and causes of medical errors in the ICUs of Iran. In this cross-sectional study, data from the family complaint files referred to The disciplinary authority of Iran Medical Council was retrospectively reviewed to explore the causes of medical errors. Statistical analysis was performed in SPSS Version 26.0. A total of 293 complaint files were referred to the disciplinary commission from 2014 to 2019, of which 95 files were related to medical errors in ICUs. The median age of patients was 62 years (46-74 years) and 52 (54.7%) patients were men. Also, 37 (38.9%) patients had decreased levels of consciousness and 42 (42.2%) patients had cardiovascular disease. A total of 40 (42.1%) patients experienced a single medical error and 55 (57.9%) patients experienced more than 1. Causes of medical errors in patients were physician's or nurse's negligence in 53 (55.8%) patients, weak interaction of physician and nurse with the patient and family members in 11 (11.6%) patients, weak interprofessional interaction among physicians in 7 (7.4%) patients, equipment and structure of ICUs in 7 (7.4 patients, nature of ICUs and patients in 6 (6.3%) patients, weak physician-nurse interprofessional interaction in 5 (5.2%) patients) patients, low attention of the physician and the nurse to medication safety in 6 (6.3%) patients. Patient safety is impacted by a variety of medical mistakes. Interprofessional strategies can be developed and put into action to mitigate medical errors in ICUs.

Root cause analysis of medication errors of the most frequently involved active substances in paediatric patients

Use of medicinal products in paediatric patients is identified as a risk factor for the occurrence of medication errors. To describe and identify root causes of medication errors in children and adolescents spontaneously reported to Agency for Medicinal Products and Medical Devices of Croatia (Agency). Agency's adverse drug reaction database was searched by using the Standardised MedDRA Query: medication errors (Broad) with data lock point set at 30th June 2022. Cases in which medication errors occurred in patients up to 18 years of age were analysed according to the patients' age group and gender, reporter's qualification, seriousness, reported preferred terms and active substances. For the first 30 most frequently reported active substances, an in-depth analysis was performed to identify the root cause of medication errors. Altogether, 6254 reports were spontaneously reported to the Agency, out of which 1947 (31%) contained at least one preferred term belonging to Standardised MedDRA Query medication errors. More than half of patients experiencing medication errors belonged to the age group 2-11 years (66%) and male gender (53%). The most frequently reported ME PTs included accidental exposure to product by a child (64%) and accidental overdose (17%). Medication error root causes for the first 30 most frequently involved active substances included misinterpretation of prescribed dosage due to a very small volume resulting in salbutamol overdose; replacing millilitre and milligram units resulting in paracetamol solution overdose; interchange between medicinal products due to primary package similarities resulting in cholecalciferol overdose and interchange between oral solution and syrup resulting in valproate overdose. Healthcare professionals should counsel caregivers about the importance of keeping medicinal products out of children's reach and provide detailed instructions on how to appropriately use medicinal products.

A Threat To Patient Safety: Medication Errors, Reporting Of Medication Errors And The Concerns With Regard To Nurses

The World Health Organization reports that approximately ten million people become permanently disabled or die each year due to medical errors. For this reason, WHO calls for a worldwide research on patient safety. Medication errors are among the most common incidents encountered in hospitals and pose a threat to patient safety. Nurses assume significant roles in preventing or reducing the errors experienced as they are the people who most frequently come into contact with the patients. Focusing on the underlying causes of medication errors, raising awareness about incident reporting and developing solutions for the root causes of errors are the main factors in ensuring patient safety. This review focuses on identifying the medication errors encountered in health care institutions, ensuring learning from mistakes by duly reporting incidents and thus improving patient safety.

A hybrid HFACS model using DEMATEL-ORESTE method with linguistic Z-number for risk analysis of human error factors in the healthcare system

The human error factor is one of the leading causes of medical errors. Among risk analysis techniques for human error factors, HFACS (Human Factor Analysis and Classification System) method has been regarded as one of the most valuable approaches due to its advantage in potential failure classification. However, the conventional HFACS method is insufficient to handle the risk analysis problem for human error factors considering the interactive relationship among these factors. Moreover, the current fuzzy HFACS frameworks cannot address quantitative risk analysis issues, including imprecision and reliability of information. Thus, this paper constructs an integrated linguistic Z-number-based HFACS framework for analyzing the risk of human error factors. This framework can capture the uncertainty and reliability of the risk evaluation information and the interactive relationships among factors. First, the linguistic Z-number-DEMATEL (Decision Making Trial and Evaluation Laboratory) method is used to generate the comprehensive risk matrix of human error factors identified by the HFACS method. Then, an extended linguistic Z-number-ORESTE method based on the score function is presented to prioritize the risk of human error factors, which can show the preference, indifference, and incomparability relationship among human error factors. Finally, a case study of a healthcare system is conducted to illustrate the reliability of the proposed method. The result of this case indicates that inadequate resources are the most severe risk. Sensitivity analysis and comparative analysis indicate the necessity of considering the effect of the semantics of language terms and the interrelationships between human error factors on risk analysis results. These results show that the proposed hybrid framework is a reliable means to analyze the risk of human error factors within the HFACS method.

Perceptions and attitudes of pediatricians and families with regard to pediatric medication errors at home

PurposeThis study aimed to identify the perceptions and attitudes of pediatricians and parents/caregivers regarding medication errors at home, and to compare the findings from the two populations.MethodsThis was a cross-sectional survey study. We designed a survey for working pediatricians and another one for parents or caregivers of children aged 14 years and younger. The survey’s questions were designed to assess provider and parental opinions about the difficulty faced by parents providing medical treatment, specific questions on medication errors, and on a possible intervention program aimed at preventing pediatric medication errors. Pediatrician and parent responses to matching questions in both surveys were compared.ResultsThe surveys were administered in Spain from 2019 to 2021. In total, 182 pediatricians and 194 families took part. Most pediatricians (62.6%) and families (79.3%) considered that managing medical treatment was not among the main difficulties faced by parents in caring for their children. While 79.1% of pediatricians thought that parents consulted the internet to resolve doubts regarding the health of their children, most families (81.1%) said they consulted healthcare professionals. Lack of knowledge among parents and caregivers was one of the causes of medication errors most frequently mentioned by both pediatricians and parents. Most pediatricians (95.1%) said they would recommend a program designed to prevent errors at home.ConclusionsPediatricians and families think that medical treatment is not among the main difficulties faced by parents in caring for their children. Most pediatricians said they would recommend a medication error reporting and learning system designed for families of their patients to prevent medication errors that might occur in the home environment.

The interactive medical simulation toolkit (iMSTK): an open source platform for surgical simulation

Introduction: Human error is one of the leading causes of medical error. It is estimated that human error leads to between 250,000 and 440,000 deaths each year. Medical simulation has been shown to improve the skills and confidence of clinicians and reduce medical errors. Surgical simulation is critical for training surgeons in complicated procedures and can be particularly effective in skill retention.Methods: The interactive Medical Simulation Toolkit (iMSTK) is an open source platform with position-based dynamics, continuous collision detection, smooth particle hydrodynamics, integrated haptics, and compatibility with Unity and Unreal, among others. iMSTK provides a wide range of real-time simulation capabilities with a flexible open-source license (Apache 2.0) that encourages adoption across the research and commercial simulation communities. iMSTK uses extended position-based dynamics and an established collision and constraint implementations to model biological tissues and their interactions with medical tools and other tissues.Results: The platform demonstrates performance, that is, compatible with real-time simulation that incorporates both visualization and haptics. iMSTK has been used in a variety of virtual simulations, including for laparoscopic hiatal hernia surgery, laparoscopic cholecystectomy, osteotomy procedures, and kidney biopsy procedures.Discussion: iMSTK currently supports building simulations for a wide range of surgical scenarios. Future work includes expanding Unity support to make it easier to use and improving the speed of the computation to allow for larger scenes and finer meshes for larger surgical procedures.

Incidence and root causes of medication errors by anesthetists: a multicenter web-based survey from 8 teaching hospitals in Ethiopia

BakgroundThe operating room is a demanding and time-constrained setting, in comparison to primary care settings, where perioperative medication administration is more complicated and there is a high risk that the patient will experience a medication error. Without consulting the pharmacist or seeking assistance from other staff members, anesthesia clinicians prepare, deliver, and monitor strong anesthetic drugs. The purpose of this study was to determine the Incidence and root causes of medication errors by anesthetists in Amhara region, Ethiopia.MethodsA multi-center cross sectional web-based survey study was conducted from October 1 to November 30, 2022, across eight referral and teaching hospitals of Amhara region. A self-administered semi structured questionnaire was distributed using survey planet. Data analysis was conducted using SPSS version 20. Descriptive statistics were computed and binary logistic regression was used for data analysis. A p-value < 0.05 was considered statistically significant.ResultsThe study included 108 anesthetists in total, yielding a response rate of 42.35%. Out of 104 anesthetists, Majority of participants (82.7%) were male. During their clinical practice, more than half (64.4%) of participants experienced atleast one drug administration error. 39 (37.50%) of the respondents revealed that they experienced more medication errors while on night shifts. Anesthetists who did not always double-check their anesthetic drugs before administration had a 3.51 higher risk of developing MAEs compared to those who always double-check anesthetic drugs before administration (AOR = 3.51; 95% CI: 1.34, 9.19). Additionally, participants who administer medications that have been prepared by someone else are about five times more likely to experience MAEs than participants who prepare their own anesthetic medications prior to administration (AOR = 4.95; 95% CI: 1.54, 15.95).ConclusionThe study found a considerable rate of errors in the administration of anaesthetic drugs. The failure to always double-check medications before administration and the use of drugs prepared by another anaesthetist were identified to be underlying root causes for drug administration errors.

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs

BackgroundSafe and effective physician-to-physician patient handoffs are integral to patient safety. Unfortunately, poor handoffs continue to be a major cause of medical errors. Developing a better understanding of challenges faced by health care providers is critical to address this continued patient safety threat. This study addresses the gap in the literature exploring broad, cross-specialty trainee perspectives around handoffs and provides a set of trainee-informed recommendations for both training programs and institutions.MethodsUsing a constructivist paradigm, the authors conducted a concurrent/embedded mixed method study to investigate trainees’ experiences with patient handoffs across Stanford University Hospital, a large academic medical center. The authors designed and administered a survey instrument including Likert-style and open-ended questions to solicit information about trainee experiences from multiple specialties. The authors performed a thematic analysis of open-ended responses.Results687/1138 (60.4%) of residents and fellows responded to the survey, representing 46 training programs and over 30 specialties. There was wide variability in handoff content and process, most notably code status not being consistently mentioned a third of the time for patients who were not full code. Supervision and feedback about handoffs were inconsistently provided. Trainees identified multiple health-systems level issues that complicated handoffs and suggested solutions to these threats. Our thematic analysis identified five important aspects of handoffs: (1) handoff elements, (2) health-systems-level factors, (3) impact of the handoff, (4) agency (duty), and (5) blame and shame.ConclusionsHealth systems, interpersonal, and intrapersonal issues affect handoff communication. The authors propose an expanded theoretical framework for effective patient handoffs and provide a set of trainee-informed recommendations for training programs and sponsoring institutions. Cultural and health-systems issues must be prioritized and addressed, as an undercurrent of blame and shame permeates the clinical environment.

Medico legal aspects of medical malpractice dead cases in Cairo and Giza governorates from 2014–2015

BackgroundIn Egypt, as elsewhere around the world, there are more medical malpractice claims and lawsuits being brought against doctors and hospitals. The present study attempts to identify the medico-legal aspects of medical malpractice cases, determine the most frequent causes of medical errors, and the most medical specialities facing this problem and their qualifications. Find out the positive cases from the negative ones, and determine the causes of their death.MethodsThis study is a retrospective descriptive observational study of medical malpractice dead cases in Cairo and Giza governorates from the available records and reports of the Forensic Medical Authority from the 1st of January 2014- to the 1st of January 2015 which included 112 cases with alleged medical malpractice dead cases. The outcomes of forensic autopsies were used to distinguish between positive and negative cases.ResultsAccording to the socio-demographic data of the claimed cases, the female cases (53.6%) dominated the male cases (46.4%). The majority of accusations of medical errors were submitted due to negligence (73.68%), followed by complications within surgical therapy (15.79%). In the study, claims against obstetricians were the highest (24.1%), followed by those against anesthesiologists (20.5%), and general surgeons (17%). university hospitals have the highest percentage of positive cases (75%), followed by insurance hospitals (25%), private hospitals (15.6%), and public hospitals (11.1%).ConclusionsThe majority of the studied cases were female. Obstetricians had the most accusations in the study and the most positive cases. The most frequent medical error in the study is negligence. All of the study's cases of obstructed labour are positive, but none of the cardiac arrhythmia or heart failure cases are. The majority of cases at university hospitals were positive and the majority of cases at public hospitals were negative.

Impact of the implementation of Identification-Situation-Background-Assessment-Recommendation (ISBAR) tool to improve quality and safety measure in a lithotripsy and endourological unit.

A lack of professional communication and collaboration may be one of the main causes of medication errors. The objective was to evaluate the results of the implementation of ISBAR as a communication and safety tool in a Lithotripsy and Endourologic Unit of a tertiary public hospital. A total of 457 patients were included in a retrospective study from 2014 to 2019. Patients were divided into two groups: group A (357 patients) in which an endourological procedure was performed before march of 2018 (without the implementation of ISBAR tool) and Group B (100 patients) with the implementation of ISBAR tool. The inclusion criteria were patients accepted for surgical intervention by anaesthesiology Department and operated in the period of the study. The variables analysed included number of procedures, global, intraoperative and postoperative complications rate, urinary infection or sepsis, NPR (FMEA), percentage of suspended surgical patients and hospital stay. The postoperative complications showed no significant differences between groups, but a trend to diminishing was seen in the complication in the group B. The sepsis reduced its incidence and it was close to significant difference. The operative time was shorter in group B 119,11min (114,63-123,59) vs 115,11min (109,63-121,67) p = 0,3. The reduction in the main postoperative complication (sepsis) explained the lower hospital stay for group B. The severe adverse events detected were reduced completely. ISBAR tool was an effective patient safety tool improving quality care. To provide safe patient care and improving quality is indispensable an effective communication flow.

Causes for Medical Errors in Obstetrics and Gynaecology.

Background: Quality strategies, interventions, and frameworks have been developed to facilitate a better understanding of healthcare systems. Reporting adverse events is one of these strategies. Gynaecology and obstetrics are one of the specialties with many adverse events. To understand the main causes of medical errors in gynaecology and obstetrics and how they could be prevented, we conducted this systematic review. Methods: This systematic review was performed in compliance with the Prisma 2020 guidelines. We searched several databases for relevant studies (Jan 2010-May 2023). Studies were included if they indicated the presence of any potential risk factor at the hospital level for medical errors or adverse events in gynaecology or obstetrics. Results: We included 26 articles in the quantitative analysis of this review. Most of these (n = 12) are cross-sectional studies; eight are case-control studies, and six are cohort studies. One of the most frequently reported contributing factors is delay in healthcare. In addition, the availability of products and trained staff, team training, and communication are often reported to contribute to near-misses/maternal deaths. Conclusions: All risk factors that were found in our review imply several categories of contributing factors regarding: (1) delay of care, (2) coordination and management of care, and (3) scarcity of supply, personnel, and knowledge.

Implementation of ED I-PASS as a Standardized Handoff Tool in the Pediatric Emergency Department.

Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period. After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation. 82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention. ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

ВРАЧЕБНЫЕ ОШИБКИ ПРИ ЗАБОЛЕВАНИЯХ БРОНХО – ЛЕГОЧНОЙ СИСТЕМЫ В СВЕТЕ ПРИМЕНЕНИЯ НОВЫХ ТЕХНОЛОГИЙ

Analysis of the literature has shown that the progress of early and timely diagnosis of major lung diseases, including tuberculosis, pneumonia and oncology depends on the level of professional knowledge of doctors, the correct use of modern diagnostic technologies. Unfortunately, not all actions of medical workers to provide medical care lead to positive results. The article describes the most common mistakes made by doctors in the diagnosis and treatment of phthisiopulmonology. For each nosological form, there are a number of diagnostic and treatment defects that reduce the clinical effectiveness of care. The vast majority of professional mistakes are made not out of ignorance, but due to inattention or self-confidence of the doctor, lack of legal literacy. Despite the ubiquitous computerization of medical institutions, the availability of state-of-the-art diagnostic equipment, the latest methods of treatment, errors in the activities of doctors of all directions do not disappear without solving the main problems of regulatory regulation. The work is of interest to novice interns, clinical residents of various specialties. Annotation The analysis of scientific publications devoted to the causes of medical errors and ways to overcome them is of increased relevance and practical significance. According to the literature, many authors sought not only to show errors in establishing a clinical and morphological diagnosis, but also to pay special attention to changes in the diagnosis of lung diseases, the impact of new innovative technologies on the effectiveness of therapeutic and surgical treatment, and tried to reflect the deontological side of the error problem. Focusing on errors in the diagnosis of pulmonary tuberculosis, pneumonia, and lung cancer recognition, it is advisable to conduct a comparative study of the diagnostic value of a number of new methods and studies that have been used in clinics for many years, to evaluate the possibilities of using modern technologies.

Interprofessional Collaboration in Patients Diabetes Mellitus: A Case Study

Interprofessional collaboration is cooperation between health professionals who work together to solve health problems, provide medical services, and achieve common goals. In the health sector, 70-80% of errors are due to poor communication and understanding within the team. In Indonesia, one result of the lack of coordination between medical personnel is the high error rate in prescribing drugs, which is up to 98.69%. Communication in the application of IPC is a very important factor that contributes to patient safety and the quality of health services so that it will form a good hospital image. Barriers to professional cooperation can be a major cause of medical errors, treatment errors, or other unforeseen events. The purpose of this study was to analyze interprofessional collaboration in the care of patients with Diabetes Mellitus. The results of the case study show that the role of the health team in collaboration in nursing care has been implemented but has not been optimal. The implementation of IPC has not been optimally implemented because there are several obstacles such as the lack of communication between professions, none of the team members have participated in the application of IPC in health services, and stereotypes from one profession to another. So it is necessary to increase teamwork between health professionals, so that collaboration can be established optimally&#x0D; &#x0D; Keywords: PPJA, Collaboration, Interprofessional Collaboration, Diabetes Mellitus

Operationalizing a Medication Safety Gap Assessment for a Large Health System.

Medication errors continue to be a leading cause of medical errors. In the United States alone, 7000 to 9000 people die annually due to a medication error, and many more are harmed. Since 2014, the Institute for Safe Medication Practices (ISMP) has advocated for several best practices in acute care facilities derived from reports of patient harm. The medication safety best practices chosen for this assessment were based on the 2020 ISMP Targeted Medication Safety Best Practices (TMSBP) and health system-identified opportunities. Each month, for 9 months, select best practices were covered with associated tools to assess the current state, document the gap, and close identified gaps. Overall, 121 acute care facilities participated in most safety best practice assessments. Of the best practices assessed, there were 8 practices that more than 20 hospitals documented as not implemented and 9 practices where more than 80 hospitals had fully implemented them. Full implementation of medication safety best practices is a resource-intensive process that requires strong change management leadership at a local level. As noted by the redundancy in published ISMP TMSBP, there is an opportunity to continue improving safety in acute care facilities across the United States.

Knowledge and perception of medication errors among health care workers in Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, North-west Nigeria.

Medication errors (MEs) are important, often overlooked forms of medical error that are associated with morbidity and mortality in health care settings. Among health care workers, knowledge, attitude and perception may affect reporting of MEs. The aim of this study was to determine the level of knowledge and perception of MEs among health care workers in Ahmadu Bello University Teaching Hospital, Zaria. A cross-sectional study was conducted among 138 health care workers selected randomly through a stratified sampling. Their responses were collected using pre-tested, self-administered questionnaires and analysed using the Statsitical Package for the Social Sciences. The numerical variables were summarised as means and standard deviations, whereas categorical variables were presented as frequencies and percentages. The Chi-square test was used to test for associations at P < 0.05. All the respondents heard of MEs and up to 108 (78.3%) correctly defined them. While only 121 (87.7%) respondents had fair to good knowledge about MEs, all of them had good perception of them. Major types of MEs known by the respondents were knowledge-based errors (79.7%), rule-based errors (52.9%), action-based errors (67.4%) and memory-based errors (55.8%). The causes of MEs identified were communication problems (88.4%), poor organizational knowledge transfer (63.8%), heavy workload (80.4%) and not reading instructions carefully (63.0%). There was no statistically significant association between the level of knowledge on MEs and sociodemographic characteristics of the respondents. Knowledge and perceptions of MEs were good among our respondents. Adequate mechanism (s) should be put in place to encourage the reporting of MEs whenever they occur to promote patient safety and improve health outcomes.

The Effect of ISBAR Tool on Patient Safety

Ineffective communication among healthcare professionals can result in a decrease in patient safety. It is a leading cause of medical errors and poor patient outcomes. This can be due to the complexity and pace of the interactions, differences in education and training, the organizational hierarchy of the professionals, and human factors such as cognitive overload, the effects of stress, fatigue, distractions, and poor interpersonal communication styles. Leaders must place value on communication. Having a standardized tool for communicating about patients is essential to the delivery of high-quality care. ISBAR is a structured method of communication that allows the person giving the handover (transmitter) and the person receiving it (receiver) to do so in a standardized &amp;amp; predictable manner. By implementing educational training on the ISBAR tool, staff at a surgery hospital are expected to have increased awareness of how they are communicating. Pre- and post-training questionnaires will be utilized, along with trends of patient outcomes. The ISBAR training should result in more effective communication and better patient outcomes. Using Argyle’s cycle of communication theory as a framework, the key elements of effective communication will be examined and how this relates to patient safety, and how using a standardized tool can improve patient outcomes.

Evaluation of Detected Medication Errors Within the Operating Room at an Academic Medical Center.

Background: Medication errors are preventable events that lead to inappropriate medication use and potential patient harm. This is especially prevalent within the operating room (OR) where one practitioner is involved in the entire medication-use process. Despite recent implementation of BD Pyxis™ Anesthesia ES, Codonics Safe Label System, and Epic One Step at the University of Kentucky Healthcare (UKHC) to prevent medication errors, errors continue to be reported. Curatolo et al found human error was the most frequent cause of medication error within the OR. Clumsy automation may be an explanation for this, which imposes burdens and promotes work arounds. This study endeavors to assess potential medication errors via chart review to identify risk reduction strategies. Methods: This a single-center retrospective cohort review of patients admitted to a UK HealthCare Main Operating Room, defined OR1A-OR5A and OR7A-OR16A, who were administered medications from 8/1/2021 to 9/30/2021. Results: Over a 2-month period, 145 cases were conducted at UK HealthCare. Of the 145 cases, 98.6% (n = 143) involved a medication error and 93.7% (n = 136) of the errors involved a high-alert medication. The top 5 classes of drugs involved in errors were all high-alert medications. Lastly, 46.6% (n = 67) of cases had documentation that Codonics was utilized. In addition to analyzing medication errors, the financial analysis found that $3154.04 in drug cost was lost in the study period. When extrapolating these results to all BD™ Pyxis Anesthesia Machines at UK HealthCare, $107 237.36 of drug cost is potentially lost per year. Conclusions: These findings add to previous data that have described the increased rate of medication errors when conducting chart review rather than rely on self-reported data. In this study, 98.6% of all cases involved a medication error. In addition, these findings provide additional insight in the increased use of technology within the operating room despite medication errors still occurring. These results can be applied to like institutions to critically evaluate anesthesia workflow to determine risk reduction strategies.

Изучение биоэтики методом кейсов: случай неправильного лечения экстрофии мочевого пузыря

Background: The principles of bioethics proposed by Beechamp and Childress are difficult to apply to the specific ethical dilemmas that arise in clinical practice. The scientific literature has suggested other ways of analyzing them. Methods: We use the Moscop's case study method to analyze a case of inappropriate treatment of bladder exstrophy, a rare con-genital condition associated with a high chance of medical error during treatment. Results: The analysis of the present case of a medical mistake considers ethical aspects such as the doctor-patient relationship, the reaction of physician-colleagues and the patient to the medical mistake, and the disclosure of the medical mistake. As a result of the bioethical analysis of the case, the following recommendations have been formed: 1) Despite the objective difficulties of treatment in a low-profile regional center and bureaucratic mechanisms of referral of the patient to another institution, the doctor should respect the autonomy of the patient and his relatives, for which full information about possible risks and treatment alternatives should be provided; 2) Disclosure of the true causes of medical error and apology can help to build trusting relationships with the patient and reduce subse-quent conflicts. Short-term psychological discomfort of disclosure will be compensated by long-term positive results of interaction with patients; 3) Criticism of previous treatment should take into account possible difficulties of diagnostics at regional level and lack of experience in treatment of rare pathologies. Achieving an advantage over one's colleagues through pointing out their medical error without knowing the real reasons for the prior treatment is ethically unjustified. Conclusion: An important function of disclosing medical errors is to warn colleagues against such errors. Most authors are of the opinion that it is the professional duty of a doctor who witnesses an adverse event to assist in the disclosure of an error and help in minimizing its consequences, however, in a medical environment with strong corporate ties and cultivating a spirit of solidarity, this principle has not become widespread in practice.