Errors In Clinical Management Research Articles

Improvement in Blood Transfusion Safety: Using Root Cause Analysis

Objectives: This research aimed at analyzing the adverse events reported related to blood transfusion in one of the large vice-chancellorships of Iran University of Medical Sciences in spring 2018. Methods: This descriptive study was performed based on the eight stages of the root cause analysis (RCA) of healthcare events by the National Authority for Health. For classification of the considered concerns, the “classifying nursing errors in clinical management (NECM)” model, failure classification, approved by the UK National Health System, and also a creative problem-solving technique were used for determining the improvement solutions. Results: Based on the results, 70% of states of blood transfusion error and blood products were placed in the category of care errors, 10% in the communication category, 20% in the category of implementation errors, and 0% in the category of knowledge and skill errors. A total of 38 influencing factors were identified for adverse events of blood transfusion, the most cause of the error was associated with organizational factors (18.4%), and the least reasons for failure were equipment and resource factors (5.3%). Conclusions: The establishment of advanced systems for the automatic transmission of blood and blood products, due to the lack of proper infrastructure in Iran, is not economically feasible. Therefore, at the level of this deputy, the guideline for managing blood transfusion and blood products in the two areas of "measures required before, during, and after blood transfusion and blood products" and "hemovigilance for physicians" were developed.

Incidence of false-positive transmissions during remote rhythm monitoring with implantable loop recorders

Implantable loop recorder (ILR) is preferred strategy for prolonged rhythm monitoring. The purpose of this study was to report the incidence and causes of false-positive (FP) diagnoses during remote monitoring with ILR. During a 4-week study period, all consecutive remote transmissions in patients with ILR (Reveal LINQ, Medtronic) implanted for atrial fibrillation (AF) surveillance, cryptogenic stroke (CS), and syncope were reviewed. A nurse specializing in device management and an electrophysiologist adjudicated all transmissions. Primary endpoint of the study was incidence of FP in patients with AF, CS, and syncope. A total of 695 remote transmissions (scheduled downloads: 414; Alerts: 281) sent from 559 patients were adjudicated. The majority of patients had ILR for AF surveillance (n = 321), followed by CS (n =168) and syncope (n = 70) with nominal programming for rhythm diagnosis. Incidence of FP transmissions during the study period was 46%, 86%, and 71% in patients with AF, CS, and syncope, respectively. Incidence of FP transmissions was higher in patients with CS and syncope than in patients with AF (P <.001). For scheduled transmissions, primary causes of FP were signal dropout and undersensing; for alert transmissions, primary reasons for FP were premature atrial and ventricular ectopy. Incidence of FP during remote monitoring with nominal settings on this ILR was substantial, ranging from 46% to 86% depending on the indication for implantation. Adjudication of these transmissions required a considerable time commitment from electrophysiologists and device clinic personnel but would be required to avoid misdiagnosis and potential errors in clinical management.

Clinical errors: Implementing root cause analysis in an area health service

ABSTRACT Introduction: Medical errors are considered as threatening the patients’ health and well-being in healthcare and treatment systems. There are various methods offered for managing the clinical risks and ensuring the healthcare quality and patient safety. Root cause analysis (RCA) is one of these methods. So, the current research paper aims at radically analyzing seven sentinel events reported to one of the large vice-chancellorships in Medical Sciences Universities in Iran. Method: The present study is a descriptive research which has been carried out based on a qualitative-retrospective method according to the eight stages elaborated in root cause analysis of healthcare events determined by National Authority for Health. To classify the identified problems, there was made use of ‘classifying nursing errors in clinical management (NECM)’ model, error cause classification, approved by the UK National Health System and then an innovative problem-solving method was applied to determine the improvement solutions. The information about the items in RCA forms was collected after obtaining a consensus of experts’ panel views via interviews and focus group discussion sessions. Findings: For the 7 sentinel events, 30 problems related to the service or healthcare was identified. Out of the 30 identified problems, the most problem related to care problems (45.4%) and the least frequent problem related to knowledge and skill problems (14.5%). Inter alia the 406 influential causes mentioned, the most frequent cause error modes pertained to organizational factors (20.1%) and the least frequent cause error modes referred to patient-related and patient-companion related factors (6.1%). Moreover, the highest rate of interventions was taken in such areas as human resources management and implementing and monitoring suitable changes in clinical processes. Conclusion: According to the usefulness of error root cause analysis in regard to such issues as patients’ safety, the systematic evaluation of sentinel events and incidents in sectors offering healthcare and treatment services is recommended. It is evident that the success of the corrective interventions in healthcare and treatment centers depends on policy-making and corroboration of the executive and supervisory levers and it is not possible without full-scale coordination and support by the various sectors connected to the social health.

Clinical negligence

The number of clinical negligence claims in the UK is constantly increasing. As a specialty, trauma and orthopaedic surgery has one of the highest numbers of negligence claims. 1 This study analyses NHS Litigation Authority (NHSLA) claims in trauma and orthopaedics between 2004 and 2014. A formal request was made to the NHSLA under the Freedom of Information Act in order to obtain all data related to claims against orthopaedic surgery. It was found that the number of claims, and percentage of successful claims, has been constantly increasing over this period, with compensation paid of over £349 million.* Errors in clinical management accounted for the highest number of closed claims (2933 claims), costing over £119 million.* The level of compensation paid out has a significant financial impact on the NHS. Reforms need to be made in order to tackle the high cost of legal fees generated by these claims, which further drain the limited resources available to the NHS.

Nurses discuss bedside handover and using written handover sheets

The analysis of nursing errors in clinical management highlighted that clinical handover plays a pivotal role in patient safety. Changes to handover including conducting handover at the bedside and the use of written handover summary sheets were subsequently implemented. The aim of the study was to explore nurses' perspectives on the introduction of bedside handover and the use of written handover sheets. Using a qualitative approach, data were obtained from six focus groups containing 30 registered and enrolled (licensed practical) nurses. Thematic analysis revealed several major themes. Themes identified included: bedside handover and the strengths and weaknesses; patient involvement in handover, and good communication is about good communicators. Finally, three sources of patient information and other issues were also identified as key aspects. How bedside handover is delivered should be considered in relation to specific patient caseloads (patients with cognitive impairments), the shift (day, evening or night shift) and the model of service delivery (team versus patient allocation). Flexible handover methods are implicit within clinical setting issues especially in consideration to nursing teamwork. Good communication processes continue to be fundamental for successful handover processes.

Classifying nursing errors in clinical management within an Australian hospital

Although many classification systems relating to patient safety exist, no taxonomy was identified that classified nursing errors in clinical management. To develop a classification system for nursing errors relating to clinical management (NECM taxonomy) and to describe contributing factors and patient consequences. We analysed 241 (11%) self-reported incidents relating to clinical management in nursing in a metropolitan hospital. Descriptive analysis of numeric data and content analysis of text data were undertaken to derive the NECM taxonomy, contributing factors and consequences for patients. Clinical management incidents represented 1.63 incidents per 1000 occupied bed days. The four themes of the NECM taxonomy were nursing care process (67%), communication (22%), administrative process (5%), and knowledge and skill (6%). Half of the incidents did not cause any patient harm. Contributing factors (n=111) included the following: patient clinical, social conditions and behaviours (27%); resources (22%); environment and workload (18%); other health professionals (15%); communication (13%); and nurse's knowledge and experience (5%). The NECM taxonomy provides direction to clinicians and managers on areas in clinical management that are most vulnerable to error, and therefore, priorities for system change management. Any nurses who wish to classify nursing errors relating to clinical management could use these types of errors. This study informs further research into risk management behaviour, and self-assessment tools for clinicians. Globally, nurses need to continue to monitor and act upon patient safety issues.

Precision Assessment and Radiation Safety for Dual-Energy X-Ray Absorptiometry

Measurement of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA) is used to diagnose osteoporosis, assess the risk of fracture, and monitor changes in BMD over time. Because biological changes in BMD are usually small in proportion to the error inherent in the test itself, interpretation of serial BMD tests depends on knowledge of the smallest change in BMD that is beyond the range of error. This value, called the least significant change (LSC), varies according to the instrument used, the patient population being tested, the measurement site, the skill of the technologist at positioning the patient and analyzing the test, and the confidence interval used in the calculation. The precision and LSC values provided by the manufacturer cannot be applied to clinical bone densitometry centers because of the differences in the patients being tested and the technologist performing the test. Because harmful errors in clinical management may occur from incorrectly interpreting serial BMD tests, it is recommended that every DXA technologist conduct a precision assessment and calculate the LSC for each measurement site and DXA instrument used. Precision assessment provides direct benefit to patients by allowing clinicians to make clinical decisions based on genuine change or stability of BMD. The patient-care benefits of precision assessment outweigh the risk of exposure to trivial doses of ionizing radiation.

Fingerstick Glucose Determination in Shock

To evaluate the accuracy of fingerstick glucose measurements in severely hypotensive patients. Prospective, nonrandomized comparison study. Emergency department in a university hospital. Twenty-five severely hypotensive patients (systolic blood pressure less than or equal to 80 mm Hg) and 39 normotensive patients. Simultaneous fingerstick reagent strip glucose, venous reagent strip glucose, and laboratory glucose values were compared. Data were analyzed using error-grid analysis. In hypotensive patients, the mean fingerstick glucose values were significantly lower than the values obtained either by venous reagent strip or laboratory glucose measurements. Fingerstick glucose values in the hypotensive group were 67.5% of laboratory glucose values, and were significantly lower than the values obtained in the normotensive group (91.8%, P less than 0.001). Only 36% of the hypotensive patients had fingerstick glucose values within the acceptable range of 20% of the laboratory glucose value. Thirty-two percent of hypotensive patients were incorrectly diagnosed as hypoglycemic (glucose less than 3.89 mmol/L [70 mg/dL]); 2 of these patients were actually hyperglycemic (glucose greater than 11.10 mmol/L [200 mg/dL]). Venous reagent strip measurements accurately reflected laboratory glucose values in both hypotensive and normotensive patients. Fingerstick glucose testing does not accurately represent venous glucose levels in severely hypotensive patients. If fingerstick glucose testing is relied on for these patients, errors in clinical management may be made. Venous reagent strip glucose testing correlates well with laboratory glucose measurements and should be the preferred method for rapid assessment of glucose level in critically ill patients with severe hypotension.