Error Prevention Research Articles

Heuristic Evaluations of Back-Support, Shoulder-Support, Handgrip-Strength Support, and Sit-Stand-Support Exoskeletons Using Universal Design Principles

Occupational Applications Our study evaluated four occupational exoskeletons using universal design principles, and we found that the exoskeleton design needs improvement to achieve equitable use by diverse worker sets (including disabled, older, and women workers). Assembling exoskeletons for use, donning and doffing wearable devices, and disassembling them can all be difficult because of the strength, dexterity, reach, and balance requirements of users. Workers with disabilities are likely to require additional support from another person to assemble or use these devices. Exoskeleton design can be improved to provide feedback on user actions, error prevention, and recovery. Factors such as assembly and storage space demands, training needs, additional personnel to assist users, and personalization costs could pose substantial barriers in industrial adoption.

Utilization of Intelligent Systems for Error Prevention during Takeoff and Landing

Utilization of Intelligent Systems for Error Prevention during Takeoff and Landing

Implementation of Medication-related Technology and Its Impact on Pharmacy Workflow: A Real-World Evidence Study from 2017 to 2023.

Medication errors constitute a major contributor to patient harm, driving up healthcare costs and representing a preventable cause of medical incidents. Over the past decade, many hospitals have integrated various medication-related technologies into their pharmacy operations. However, real-world evidence on the impact of these advanced systems on clinical prescription dispensing error rates remains limited. This study aims to prospectively detect and record the categories and rates of dispensing errors to illustrate how medication-related technologies, such as automated dispensing cabinet (ADC), barcode medication administration (BCMA), and smart dispensing counter (SDC), can be utilized to minimize dispensing errors. This study employed a before-and-after design at a 2,202-bed academic medical center in Taiwan to assess the impact of implementing medication-related technologies (ADC, BCMA, and SDC) on patient medication safety. Dispensing error rates were analyzed from January 1, 2017, to December 31, 2023, using data from the China Medical University Hospital Patient Safety Database (CMUH PSD). The study periods were defined as follows: stage 0 (pre-intervention, January 2017-November 2017), stage 1 (post-ADC intervention, December 2017-June 2018), stage 2 (post-BCMA intervention, July 2018-October 2020), and stage 3 (post-SDC intervention, November 2020-December 2023). Medication errors were defined according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Chi-square or Fisher's exact tests were used to analyze differences between intervention periods, with Bonferroni correction for multiple comparisons. Statistical significance was set at P<.05. Following the introduction of medication-related technologies, the average dispensing error incidence rate significantly decreased by 39.68% (Stage 1), 44.44% (Stage 2), and 77.78% (Stage 3), from 0.0063% in Stage 0 (pre-intervention) to 0.0038% (Stage 1), 0.0035% (Stage 2), and 0.0014% (Stage 3), respectively. The frequency of "wrong drug" errors, the most common error type in Stage 0, significantly decreased by 51.15%, 56.85%, and 81.26% in Stages 1, 2, and 3, respectively. All error types, except for "wrong dosage form," "wrong strength," "wrong time," and "others," demonstrated statistically significant differences (P<.001). The majority of harm severities were categorized as "A" (no error) (97.0%-98.8%) and "B-D" (error, no harm) (1.2%-3.0%) according to the NCC MERP classification. The severity of "no error" (Category A) significantly decreased at each stage (P<.001). Statistically significant differences in dispensing error rates were observed between all stages (P<.001), except between Stage 2 and Stage 1 (P>.99). This study provides significant evidence that the implementation of medication-related technologies, including ADC, BCMA, and SDC, effectively reduces dispensing errors in a hospital pharmacy setting. Specifically, we observed a substantial decrease in the average dispensing error rate across three stages of technology implementation. Importantly, this study appears to be the first to investigate the combined impact of these three specific technologies on dispensing error rates within a hospital pharmacy.

Misdiagnoses in the diagnostics of the abdomen and pelvis

Misdiagnoses in abdominal radiology are afrequent source of clinical errors, often stemming from cognitive biases and perception errors. Typical sources of error include perceptual and interpretative issues, frequently influenced by cognitive mechanisms, such as anchoring and confirmation biases or the satisfaction of search bias. Technical errors, such as suboptimal windowing in computed tomography, also contribute to diagnostic inaccuracies. Enhancing diagnostic accuracy requires awareness of these biases and asystematic reflection on the diagnostic process. This approach enables early error prevention and improves the diagnostic quality in abdominal imaging.

Unit dose drug dispensing systems in hospitals: a systematic review of medication error reduction and cost-effectiveness

BackgroundMedical errors pose significant risks to patient safety and public health. Automated unit dose drug dispensing systems (UDDSs) have emerged as valuable tools to reduce medication errors while optimising economic...

Data Organization in Spreadsheets

This review paper primarily focuses on the document "Data Organization in Spreadsheets" by [1], which offers a practical guide to organizing spreadsheet data effectively. Emphasizing foundational principles such as consistency, simplicity, and reproducibility, the document provides actionable advice to minimize errors, improve collaboration, and ensure data integrity. Through this analysis, the review highlights the document's strengths, including its alignment with the "tidy data" paradigm and emphasis on error prevention and reproducibility. Additionally, the review discusses limitations, such as the lack of advanced spreadsheet techniques and domain-specific examples, and suggests enhancements like incorporating case studies and introducing programming tools like R and Python for scalable workflows. This review situates the document within broader data management practices, connecting it to key works in the field, such as those by [2], [4] and [5],further enriching its context and applicability

Usability Evaluation Satu Sehat Application Using Heuristic Evaluation Method

Digital transformation in the health sector aims to improve efficient, effective, and integrated services. The government has started building mobile-based applications in various fields. Satu Sehat application is one of mobile-based application developed by the Indonesian Ministry of Health. As an integrated health platform in Indonesia, faces challenges in ensuring optimal user experience. User experience is greatly influenced by a good user interface. User interface must have good usability aspect so that users will feel comfortable when using the application. This study aims to evaluate the usability of the application using the Heuristic Evaluation method, by identifying problems based on Nielsen's 10 heuristic principles. Evaluation was conducted by 5 evaluators who have expertise in interaction design, health technology, and usability analysis. The results reveal two problems in error prevention and one problem in help and documentation, which are the basis for recommendations for further development. Recommendations are given on several aspects to improve the user experience.

Quality Assurance and Quality Improvement Research.

Quality assurance and quality improvement initiatives are being performed widely across the respiratory care profession. Common goals of quality assurance and quality improvement include the detection and prevention of errors, establishment of standards to improve respiratory care practice, and overall delivery of quality care to the patient. For these reasons, respiratory care departments participate in quality assurance and quality improvement initiatives at multiple levels: (1) interdepartmental (hospital/systemwide/multi-center), (2) intradepartmental (local/respiratory care department), or (3) grassroots approach (bottom-up approach). Utilization of a systematic approach to quality assurance and quality improvement is essential in ensuring the work is germane, and using appropriate research methodology can assure the results can benefit a generalized audience. A description of quality assurance and quality improvement research is presented with considerations and examples from Respiratory Care.

The prevention of medication errors in the home care setting: a scoping review.

The changes in health, social and demographic needs impose new approaches to cures and care without giving up patients' safety. Although several studies analysed the patient safety approach and strategies, the literature considering the home care setting seems still scarce. The analysis of the phenomenon of medication errors in the primary care setting highlights the necessity of exploring the specific variables to understand how to prevent or reduce the occurrence of a medication error in the home context. This review investigates the main preventive strategies implemented at the patient's home to prevent and/or limit the possibility of a medication error. The scoping review was conducted under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement and based on the guidelines of the Joanna Briggs Institute. No time or language limit was set to obtain the most comprehensive results possible. The following databases were queried: PubMed, Cochrane, CINAHL, ERIC and PsycINFO via EBSCO. All literature published up to 31 December 2022 was considered for data collection. The main preventive strategies implemented in the patient's home to prevent a medication error are: Multidisciplinary teams, therapeutic reconciliation and computerised systems that improve information sharing. As evidenced by all of the included studies, no educational intervention or preventive strategy individually reduces the risk of making a medication error. It would be desirable for healthcare professionals to be constantly updated about their knowledge and understand the importance of introducing the aforementioned preventive strategies to guarantee safe care that protects the person from medication errors even at the patient's home.

Future time perspective and incident involvement among civil pilots: the mediating role of vocational calling and the moderating role of perceived organizational support

Objectives. Incident involvement among pilots has been a major human factor safety concern. Enhancing safety by reducing accidents and improving pilot behaviour is vital for aviation safety. Future time perspective (FTP) has been found to be a protective factor in safety behaviour. The aim of this study was to explore the impact of FTP on safe flight performance and the underlying mechanisms. Methods. The model was examined with 514 Chinese civil pilots; the participants completed measurements regarding FTP, vocational calling, perceived organizational support (POS) and incident involvement. Results. The correlation analyses indicated that FTP was significantly negatively associated with pilot incident involvement, and POS was significantly negatively associated with pilot incident involvement. Mediation analyses revealed that vocational calling partially mediated the link between FTP and pilot incident involvement. Moderated mediation further indicated that POS moderated the negative mediation path of FTP on pilot incident involvement. Conclusion. This study reveals the mechanism of FTP in the maintenance of flight safety, which enriches the research system of human error prevention research, and provides certain suggestions for aviation safety culture.

Prevention of judicial errors and their prevention using AI

The article is devoted to the study of the possibilities of digitalization, artificial intelligence in preventing judicial errors and increasing access to justice. The study emphasizes the importance of digital technologies in the legal sphere, including the automation of judicial processes and modeling of judicial decisions, being an important step to ensure justice. The literature review analyzes international experience in using digital tools in various sectors, including the legal system, and identifies their potential for minimizing judicial errors. The research methodology is based on the use of predictive analysis of the integration of artificial intelligence into the judicial system, as well as a comparative analysis of foreign experience. The results show that digitalization of artificial intelligence-based systems, can increase the efficiency and transparency of justice, improve the quality of decisions and reduce the number of judicial errors. The discussion focuses on the need to adapt international experience to Kazakhstan's realities and develop a regulatory framework for the integration of artificial intelligence into the judicial system. The analysis highlights that successful digitalization requires a comprehensive approach, including technology development, training of specialists and creation of a transparent legal framework, suggesting directions for future work in the field of digitalization of justice, emphasizing the importance of interaction between people and technology.

Analyzing the impact of blood collection errors on patient safety and clinical outcomes⁠

Errors in blood collection processes pose a significant challenge to healthcare systems, contributing to diagnostic inaccuracies, compromised patient safety, and adverse clinical outcomes. Pre-analytical errors, including patient misidentification, improper labeling, hemolysis, and sample contamination, are among the most common sources of laboratory mistakes. These errors can delay diagnosis, lead to unnecessary medical interventions, and increase healthcare costs. Misidentification and labeling errors, for example, have been linked to life-threatening outcomes in transfusion medicine, while hemolysis often results in falsely elevated laboratory values that can mislead clinical decision-making. Effective strategies to address blood collection errors include leveraging technological innovations, such as barcoding systems and automated labeling, which have demonstrated success in reducing mislabeling incidents. Adherence to standardized guidelines, including protocols established by the Clinical and Laboratory Standards Institute (CLSI), plays a crucial role in maintaining sample integrity. Additionally, phlebotomy training programs and competency assessments ensure that healthcare staff consistently follow best practices, minimizing errors during the collection process. Quality management tools, including Six Sigma and Lean methodologies, further enhance laboratory processes by identifying root causes of errors and implementing targeted improvements. Patient engagement also contributes to error prevention, with informed and active participation serving as an additional safeguard against potential mistakes. The integration of these strategies has shown promise in improving diagnostic reliability and reducing the clinical and economic burden of blood collection errors. By addressing systemic, procedural, and technological factors, healthcare systems can ensure safer and more accurate diagnostic practices, ultimately enhancing patient outcomes. A multidisciplinary focus remains essential for achieving sustainable improvements in blood collection processes and mitigating risks associated with pre-analytical errors.

Implementation of an information system for tuberculosis in healthcare facilities in Indonesia: evaluation of its effectiveness and challenges

BackgroundTuberculosis (TB) surveillance in Indonesia is currently supported by the recording and reporting technology Tuberculosis Information System (Sistem Informasi Tuberkulosis [SITB]). SITB is used by all health workers responsible for TB programs in health facilities or hospitals throughout Indonesia. The satisfaction and ease of use of SITB affect the speed and accuracy of TB case reporting. Therefore, evaluating the information system’s quality is crucial. SITB utilization is comprehensively assessed using the End-User Computing Satisfaction (EUCS) method, which considers the dimensions of content, accuracy, timeliness, and ease of use. Furthermore, the effectiveness of the user interface using heuristic evaluation methods is critical. The primary objective of this study is to conduct a comprehensive evaluation of the System for Information on Tuberculosis (SITB) focusing on its usability and user satisfaction.MethodsThis study employed a multi-method design approach. First, a heuristic evaluation was conducted by three expert user experience designers. Second, a cross-sectional survey of 115 SITB users was carried out across all health facilities in the Special Region of Yogyakarta, Indonesia, for reporting TB cases, using the EUCS method. Finally, in-depth interviews were conducted in 10 health facilities, focusing on identifying specific attributes that needed improvement to enhance user satisfaction.ResultsThe evaluation indicated that user convenience and timeliness require improvement, as well as the match between the system and the real world and error prevention, as shown in the heuristic evaluation of the SITB user interface. These findings were confirmed through interviews that identified the need for user manuals, server repairs, and information and SITB forms that are suitable for TB management in the field. The overarching assessment of the SITB reveals persistent challenges in data entry, attributed to the functionality of the application, thereby potentially impacting user satisfaction.ConclusionsSITB application requires “major” improvements to make recording, reporting, and tracing activities more efficient and precise. Moreover, the integration of existing information systems in healthcare facilities is essential to support the tuberculosis surveillance reporting system in Indonesia.

Improvement Plan for the Pre-Analytical Process of the SEMEDICLAB Laboratory Period 2022

Objective: SEMEDIC is a clinical laboratory that performs tests in the areas of hematology, biochemistry, urinalysis, immunology, coprology, and immunochemistry. This work aims to implement a continuous improvement plan for the pre-analytical process of the SEMEDICLAB laboratory in 2022. Theoretical Framework: The research focuses on pre-analytical errors in clinical laboratories and their impact on the quality of results. It is based on the premise that, despite technological advances and automation, the pre-analytical phase remains a weak link in the clinical analysis process. Method: The present study adopts an observational and descriptive methodology, as it allows for the visualization of the environment in which the research is carried out. It should be noted that no population or sample was considered; it was based on the identification, definition, and standardization of sub-processes of the SEMEDICLAB company process. Clause 5.4 of the ISO 15189:2012 checklist was used to identify the gap between the sub-processes currently completed. Results and Discussion: The causes of the problem in the pre-analytical phase of the workers in the SEMEDICLAB laboratory were described, which were caused by non-compliance or omission of the ISO 15189: 2012 standard, related to clauses 5.4.2. "Information for patients and users," 5.4.4.2. "Instructions for pre-analytical activities," and 5.4.6 "Sample reception," where irregularities were observed. Implications of the research: Research on pre-analytical errors has a direct impact on the quality of patient care, the efficiency of clinical laboratories, and the sustainability of health systems. By identifying the causes of these errors and developing strategies to prevent them, it contributes to improving patient safety and the reliability of laboratory results. Originality/Value: The value of this type of research is multifaceted. Firstly, it contributes to improving the quality of patient care by reducing the incidence of erroneous laboratory results, which in turn reduces the risk of misdiagnosis and inappropriate treatment. Secondly, it optimizes processes in clinical laboratories, increasing efficiency and reducing costs associated with the repetition of tests and error management. Thirdly, this research promotes the development of standards and clinical practice guidelines for the prevention and management of pre-analytical errors, which helps to ensure the quality and safety of laboratory services at the national and international level.

Evolution of a patient safety program in an academic medical center

Background The Academic Medical Center earned a 1-Star CMS designation and received an F on the Leapfrog Safety Grade in 2015, which led to leadership setting Clinical Quality Improvement as the #1 Strategic Priority. This paper presents the evolution of a structured patient safety program as a component of this plan to direct and motivate employees to succeed in reducing patient harm. Methods Data-driven quality improvement using simple, timely, actionable data drillable scorecards available to all employees was the cornerstone of the above strategic priority. A comprehensive patient safety program was developed utilizing three phases: Error Prevention Training, Improved Event Reporting, and the Chasing Zero Harm initiative. Results Improvement was achieved in Culture of Safety Survey domains of overall safety, event reporting, nonpunitive response to errors, and hand-off communication. Patient safety indicators and hospital-acquired infections improved on the Medical Center's internal scorecard and public reported data by &gt;60%. These resulted in improvement in Leapfrog Safety Score from an F in 2015 to a B in 2023, and increase from CMS 1-Star to 2-Star rank in 2023. Adverse event reports and review with follow up increased by 45% between 2018 and 2023. A Chasing Zero harm program was initiated following establishment of these steps. Discussion A successful patient safety program, predicated on high reliability, can successfully be built with leadership commitment, development of safety culture, and performance improvement.

Pharmacological Competencies in Nursing: Prevention of Medication Errors and Patient Safety in Intensive Care Units

Introduction: Pharmacology focused on the study of the effects of chemical compounds on living organisms, consolidating itself as an essential discipline in health. Its evolution allowed significant advances in modern medicine, standing out in critical areas such as Intensive Care Units (ICU). In these environments, where patients require precise pharmacological care, medication errors (ME) were identified as one of the main causes of preventable adverse events. Institutions such as the World Health Organization (WHO) stressed the need to improve pharmacological competencies to ensure patient safety.Development: Pharmacological training in nursing proved to be a major challenge. Although emphasis was placed on key areas such as pharmacodynamics and pharmacokinetics, deficiencies were observed in practical knowledge and the ability to prevent errors in drug administration. The problem was addressed from a systemic approach using tools such as Reason's model, which made it possible to identify structural and underlying failures in pharmacotherapeutic processes. In parallel, pharmacovigilance and pharmacoepidemiology stood out as pillars to monitor the safe use of medications, promoting an organizational culture oriented to learning and continuous improvement.Conclusions: It was concluded that pharmacological competence in Nursing is fundamental to prevent medication errors and ensure patient safety. The integration of theoretical training, practical skills and ethical attitudes was key to address the challenges in critical contexts such as ICUs. In addition, it was recommended to strengthen continuous training systems and adopt interdisciplinary strategies to reduce medication-related risks and improve the quality of health care.

Impact of Pharmacological Competencies on the Reduction of Medication Errors in Critical Care Units

The use of drugs to treat disease and relieve pain has historical roots that evolved significantly over time, especially in the 20th century, when pharmacology became a central discipline in healthcare and nursing. This practice, although essential for patient recovery, especially in high-intervention settings such as intensive care units, is prone to errors that can have serious consequences for patients. The National Coordinating Council for Medication Error Prevention (NCC MERP) has developed error classification and analysis tools, emphasizing that errors are often preventable and multifactorial, highlighting the importance of nursing staff pharmacological knowledge.Several studies have identified the causes and consequences of medication errors. In Ecuador, errors were related to high patient demand, non-compliance with schedules and poor administration technique. In Cuba, a general mastery of medications was observed, but a deficiency in the recognition of adverse reactions. In Spain, pharmacovigilance showed low rates of spontaneous reporting of adverse events, attributable to insufficient training in pharmacology. In critical care units, the most common errors included administration, dilution and dosing techniques, exacerbated by pressure of care and communication problems.In this context, nursing plays a crucial role as it is at the end of the pharmacotherapeutic process, acting as the last barrier to prevent errors from reaching the patient. This study in an Intensive Care Unit in Rosario seeks to delve into this problem, highlighting its impact on patients and on the professional development of nursing staff, with the aim of providing practical and theoretical solutions

Author's Response: Prevalence and Prevention of Medication Errors in Obstetric Anesthesia Practice

Author's Response: Prevalence and Prevention of Medication Errors in Obstetric Anesthesia Practice

Prevalence and Prevention of Medication Errors in Obstetric Anesthesia Practice

Prevalence and Prevention of Medication Errors in Obstetric Anesthesia Practice

Learning experiences and coping strategies of nursing students in the face of clinical errors

Learning experiences and coping strategies of nursing students in the face of clinical errors