Errors In Medicine Research Articles

Near miss errors in transfusion medicine: the experience of the G. Gaslini transfusion medicine service.

The monitoring of near miss errors, in other words events that cannot be classified as substantial errors, but whose occurrence suggests that there is probably a critical point in a working procedure, can be useful in order to prevent these 'almost errors' from occurring again or to prevent them evolving into 'relevant errors'. The methods for picking up and studying near miss errors use widely tested systems that have recently also been applied to medicine. These systems are based on the process of identifying the risk through spontaneous notifications of events (incident reporting). In our Service of Immunohaematology and Transfusion Medicine (SIMT) these reports were assessed using root cause analysis, allowing us to introduce corrective actions to eliminate or reduce the risk. We report the distribution, type and frequency of near miss errors, divided according to the stage of the working procedure in which they occurred, and for each of them describe the possible causes and corrective actions identified. We show how the possibility of an error, with potentially harmful consequences for the patient, is present throughout the whole transfusion chain. Near miss errors in Transfusion Medicine can be included in the wider field of 'clinical risk, a problem that concerns not only SIMT, but also numerous other sectors of health care. The instruments identified through this study can lower the threshold of clinical risk in a Transfusion Service.

The real malady of Marcel Proust and what it reveals about diagnostic errors in medicine

Marcel Proust, author of À La Recherche du Temps Perdu, was considered a hypochondriac not only by the numerous specialists he consulted during his lifetime but also by every literary critic who ventured an opinion on his health, among them several clinicians. However, Proust’s voluminous correspondence, as detailed in its attention to his every symptom as his novel, provides valuable clues to Proust’s real, organic, and rare illness. Proust, in fact, was not only genuinely ill but far sicker than he even he believed, most likely suffering from the vascular subtype of Ehlers–Danlos Syndrome. Ironically, Proust’s own doctors and his clinician-critics replicated the same kinds of diagnostic errors clinicians still routinely make today, shedding light on the plight of patients with rare illnesses.

Articles That May Change Your Practice: Crew Resource Management

To err is human. Human factors refer to environmental, organizational, and job factors and individual characteristics that influence behavior and affect performance and safety. Human factors account for many of the adverse events and errors in both medicine and aviation. In 1979, crew recourse management (CRM) was introduced for aviation personnel after a number of accidents in which human factors were identified as the cause. CRM led to a decrease in events and has been shown to be essential in effective decision making during time-critical emergencies. Human factors have the same impact on patient care in clinical medicine. This is particularly true in areas in which an interprofessional workforce undertakes decisions and procedures in a time-sensitive manner. Russell D. MacDonald, MD, MPH, FCFP, FRCPC, is the medical director and chair of the Quality Care Committee at Orange Transport Medicine; an associate professor at the University of Toronto; and an attending staff member at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. He can be reached at [email protected] .

Statistical methods and errors in family medicine articles between 2010 and 2014-Suez Canal University, Egypt: A cross-sectional study.

Background:With limited statistical knowledge of most physicians it is not uncommon to find statistical errors in research articles.Objectives:To determine the statistical methods and to assess the statistical errors in family medicine (FM) research articles that were published between 2010 and 2014.Methods:This was a cross-sectional study. All 66 FM research articles that were published over 5 years by FM authors with affiliation to Suez Canal University were screened by the researcher between May and August 2015. Types and frequencies of statistical methods were reviewed in all 66 FM articles. All 60 articles with identified inferential statistics were examined for statistical errors and deficiencies. A comprehensive 58-item checklist based on statistical guidelines was used to evaluate the statistical quality of FM articles.Results:Inferential methods were recorded in 62/66 (93.9%) of FM articles. Advanced analyses were used in 29/66 (43.9%). Contingency tables 38/66 (57.6%), regression (logistic, linear) 26/66 (39.4%), and t-test 17/66 (25.8%) were the most commonly used inferential tests. Within 60 FM articles with identified inferential statistics, no prior sample size 19/60 (31.7%), application of wrong statistical tests 17/60 (28.3%), incomplete documentation of statistics 59/60 (98.3%), reporting P value without test statistics 32/60 (53.3%), no reporting confidence interval with effect size measures 12/60 (20.0%), use of mean (standard deviation) to describe ordinal/nonnormal data 8/60 (13.3%), and errors related to interpretation were mainly for conclusions without support by the study data 5/60 (8.3%).Conclusion:Inferential statistics were used in the majority of FM articles. Data analysis and reporting statistics are areas for improvement in FM research articles.

Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine

ObjectivesDiagnostic errors are common in the emergency department (ED), but few studies have comprehensively evaluated their types and origins. We analysed incidents reported by ED physicians to determine disease conditions,...

Pre-analytical phase: The automated ProTube device supports quality assurance in the phlebotomy process

BackgroundMost errors in laboratory medicine occur in the pre-analytical phase of the total testing process. Phlebotomy, a crucial step in the pre-analytical phase influencing laboratory results and patient outcome, calls for quality assurance procedures and automation in order to prevent errors and ensure patient safety. MethodsWe compared the performance of a new small, automated device, the ProTube Inpeco, designed for use in phlebotomy with a complete traceability of the process, with a centralized automated system, BC ROBO. ResultsProTube was used for 15,010 patients undergoing phlebotomy with 48,776 tubes being labeled. The mean time and standard deviation (SD) for blood sampling was 3:03 (min:sec; SD±1:24) when using ProTube, against 5:40 (min:sec; SD±1:57) when using BC ROBO. The mean number of patients per hour managed at each phlebotomy point was 16±3 with ProTube, and 10±2 with BC ROBO. No tubes were labeled erroneously or incorrectly, even if process failure occurred in 2.8% of cases when ProTube was used. ConclusionsThanks to its cutting edge technology, the ProTube has many advantages over BC ROBO, above all in verifying patient identity, and in allowing a reduction in both identification error and tube mislabeling.

Cognitive errors in medicine: Mitigation of cognitive errors

Cognitive errors in medicine: Mitigation of cognitive errors

Cognitive errors in medicine: The common errors

Cognitive errors in medicine: The common errors

Parental Experiences of Medication Administration to Children at Home and Understanding of Adverse Drug Events.

Medication administration errors are the most common type of error in pediatric medicine. Preventing medication errors is an important part of ensuring safe and quality patient care for pediatric patients. Few studies have described this issue from the perspective of the parents of pediatric patients. This study describes parents' administration of medication to their children at home and the understanding of these parents of adverse drug events (ADEs). A cross-sectional survey design was used to gather data from 179 parents of pediatric patients at two pediatric units at a hospital and three children's daycare centers in Korea. Data were collected from July to August 2012 using a self-reported questionnaire. Participants reported administering antipyretics (94.4%), decongestants (89.4%), and antibiotics (77.7%) to their children at home. The major source of medication information was instruction sheets. Parents more commonly used dosing cups (43.6%) and droppers (32.9%) when administering liquid medication to children. Furthermore, 12.3% of the children experienced ADEs. Only 48% of the participants were provided information on ADEs, 15.1% were unsure about the recommended dosage, and 11.2% were unsure of the recommended method for administering the medication. Analysis of variance and post hoc tests showed that level of parental education and monthly income each had a significant impact on participant understanding of ADEs. This study suggests that parents should be educated about ways to avoid common medication errors in children. In addition, in the case of low-income families, home visits should be carried out to understand how to reduce home medication errors and provide drug-related information to parents. Strategies are needed to reduce pediatric home medication errors and minimize ADEs and to provide medication information to parents.

Analysis of medication error in 80 healthcare institutions in the French northern region of Nord-Pas-de-Calais

The primary analysis had for its main purpose the description and characterization of 1871 medication errors reported by voluntary healthcare institutions to the Nord-Pas-de-Calais OMEDIT between 2010 and 2012. Medication errors were characterized, and the contributory or influential factors were ranked by using the new taxonomy from the Review of Errors in MEDication » (REMED V2 process) offered by the French Society of Clinical Pharmacy. Among 80 voluntary healthcare institutions, 65 reported 1856 out of 1871 medication errors. Overall, 2507 drugs were involved, and 6 groups of the Anatomical Therapeutic Chemical (ATC) classification system represented more than 90% of the medication errors. The errors of dose and medicine accounted for 72% in the cumulative frequency of drug errors reported. The prescription (39%) and administration (33%) were the two main initial stages of drug error occurrences in the medication use process. Medicines, practices and procedures, and healthcare professional areas might be the most involved in the diagnosis of contributory or influential factors associated with declared medication errors. Even though the safety culture is being developed within healthcare institutions of the area, the objective in 2013 was to achieve an expansion of the number of healthcare institutions reporting as well as to increase the number of declarations used as returns of experience. L’analyse a eu pour but principal de décrire et de caractériser les 1871 erreurs médicamenteuses (EM) déclarées par des établissements de santé (ES) volontaires à l’OMÉDIT Nord-Pas-de-Calais entre 2010 et 2012. Les EM ont été caractérisées et les facteurs contributifs ou influents ont été hiérarchisés en utilisant la nouvelle taxonomie de la revue des erreurs liees aux medicaments et dispositifs associés (REMED V2) proposée par la Société française de pharmacie clinique. Parmi les 80 ES volontaires, 65 ont déclaré 1856 des 1871 EM. Deux milles cinq cent sept médicaments ont été impliqués et six classes thérapeutiques « ATC » représentaient plus de 90 % des EM. Les erreurs de dose et de médicament représentaient 72 % en fréquence cumulée des EM déclarées. La prescription (39 %) et l’administration (33 %) ont été les deux principales étapes initiales de survenue des EM dans le circuit du médicament. Les domaines « Médicaments », « Pratiques & Procédures » et « Professionnels de santé » seraient les plus impliqués dans le diagnostic des facteurs contributifs ou influents associés aux EM déclarées. Même si la culture de sécurité commence à émerger au sein des ES de la région, l’objectif en 2013 est de parvenir à élargir le nombre d’ES déclarant ainsi que le nombre de déclarations faisant l’objet d’un retour d’expérience.

The mind of diabetes: a distressing tale

We often see in people with diabetes that the disease causes psychological and emotional difficulties. These difficulties do not only cause disruption to the person’s self-management behaviours, with detrimental effects on their physical health, they can also be very disruptive to the person’s quality of life. Over the last few decades we have become increasingly aware that psychological morbidity is common in people with diabetes, with problems ranging from depression to eating disorders. We have also observed that these problems have a deleterious effect on patient outcomes, leading to further complications that compound the psychological problems experienced by the patient. However, despite this large body of understanding and a growing evidence that psychological interventions can be clinically beneficial, national and international reports consistently highlight that psychological support is lacking in most countries. In this edition of the journal we have two papers from the same research group that address diabetes distress. Diabetes distress while related to anxiety and depression reflects some of the specific psychological disruptions that a life with diabetes can bring. In the first paper the group present a systematic review of psychological interventions that aim to reduce diabetes distress. The review presents a comprehensive account of which interventions show some impact on diabetes distress. While they report that the interventions only show a modest effect, they do provide reference points for further developments in this field. Given the high prevalence of diabetes distress we must work with patients to refine, improve and create better interventions to tackle this problem. In the second paper the authors present a more clinical example with an intervention that was designed to respond and address diabetes distress. While this report does not show a definitive approach to managing distress as it had somewhat mixed results, it does show the importance of recognising the problem and developing appropriate psychological care pathways. Screening for problems is not really an ethical activity if we have nothing to offer patients. While ideally we should be able to provide effective treatments to support them, as a minimum, we should provide empathy and understanding. Elsewhere in this edition of the International Diabetes Nursing journal we find other tricks that diabetes can play on the mind. In this case those of a more organic nature, related to the physiological assault of the disease. In the paper by Butler et al. we see more data showing elevated risk of stroke in people with diabetes. This national study of stroke in Qatar not only shows diabetes to be an important risk factor but also significant variation between ethnic groups with a higher burden in Arabs. The report emphasises the important rolewemust all play in preventing strokes. In the paperofCaruso et al. another important issue of the mind is highlighted, that of cognitive impairment. Both cognitive impairment and dementia are increased in patients with diabetes. Cognitive decline can be important in relation to a patient’s capacity to self-manage and may also increase risks of medicines errors and patient safety. Again, assessing this problem where this may be suspected might be important in supporting clinical decisions with patients and in ensuring early referral to memory services. While their study was a pilot it was encouraging that perhaps exercise and diet may help protect people from cognitive impairment. Another pilot study byKeller-Senn indicates that nurses successfully accomplish educational interventions to enhance foot care related self-efficacy. Larger studies are needed following these pilot studies. If you are lucky enough to be coming to this year’s FEND conference you will notice the programme includes some important speakers on psychological intervention in diabetes care. If you cannot attend the conference then we still encourage you to start conversations in your team and build or develop further your psychological support services. Please do evaluate these papers and share them with others via the journal. All in all, let’s be much more mindful about diabetes. Lastly, the journal would like to highlight the fantastic achievement of Debbie Jones, whose work in improving care for people with diabetes was recognised in the Queen’s honours list with the award of an OBE. Debbie is a specialist diabetes nurse working in Bermuda where she has led a range of developments to enhance the clinical care of people with diabetes. We would like to extend warm congratulations to Debbie for her great work and this fantastic achievement.

Monitoring and reporting of preanalytical errors in laboratory medicine: the UK situation.

Most errors in the clinical laboratory occur in the preanalytical phase. This study aimed to comprehensively describe the prevalence and nature of preanalytical quality monitoring practices in UK clinical laboratories. A survey was sent on behalf of the Association for Clinical Biochemistry and Laboratory Medicine Preanalytical Working Group (ACB-WG-PA) to all heads of department of clinical laboratories in the UK. The survey captured data on the analytical platform and Laboratory Information Management System in use; which preanalytical errors were recorded and how they were classified and gauged interest in an external quality assurance scheme for preanalytical errors. Of the 157 laboratories asked to participate, responses were received from 104 (66.2%). Laboratory error rates were recorded per number of specimens, rather than per number of requests in 51% of respondents. Aside from serum indices for haemolysis, icterus and lipaemia, which were measured in 80% of laboratories, the most common errors recorded were booking-in errors (70.1%) and sample mislabelling (56.9%) in laboratories who record preanalytical errors. Of the laboratories surveyed, 95.9% expressed an interest in guidance on recording preanalytical error and 91.8% expressed interest in an external quality assurance scheme. This survey observes a wide variation in the definition, repertoire and collection methods for preanalytical errors in the UK. Data indicate there is a lot of interest in improving preanalytical data collection. The ACB-WG-PA aims to produce guidance and support for laboratories to standardize preanalytical data collection and to help establish and validate an external quality assurance scheme for interlaboratory comparison.

Application of six Sigma management method in clinical oral medications dispensing

Objective To investigate how to reduce the errors of the nurse dispensing medicine by six Sigma management (SSM), to ensure patient medication safety, and improve the effective medicine treatment. Methods A total of 12 nurses from January 2012 to January 2013 were chosen as the control group, while 12 nurses from June 2013 to June 2014 were selected as the experimental group.The oral medicine dispensing was took three inspections and seven verifications in the control group while SSM was used in the experimental group. The medicine dispensing error and patient′s satisfaction were compared between two groups. Results The error rate in the control group was 2.112%, which was higher than 0.294% of the experimental group (χ2=14.4, P<0.05). The satisfaction of medicine dispensing were 98.57% and 91.26% in the experimental group and control group (χ2=15.564, P<0.05). Conclusions Six Sigma methods can effectively improve the patient′s medication safe and effective medication. Key words: Six Sigma management; Medicine dispensing, oral; Clinical nursing; Satisfaction

Choisir la forme pharmaceutique orale la plus adaptée à l’enfant

Selecting the most appropriate oral formulation is very challenging when developing medicines for children and in routine practice. Research in pediatric pharmacology has focused on oral drug formulation, determining whether the active pharmaceutical ingredient can be successfully delivered to children. Pediatric expert committees (EMA, EuFPI) recommend that children's medicines be safe, well tolerated, easy to use (palatable and requiring minimal handling), transportable, easily produced, cost effective, commercially viable, with a minimal impact on children's life-style. Oral liquid drug formulations (OLFs: solutions, syrups, suspensions) are historically considered as the most appropriate oral formulation for children, since they are easy to swallow for younger infants and palatable for children. However, OLFs present numerous disadvantages, such as low stability, potentially toxic excipients for children, and low transportability. In the long-term, dose volume and frequency of administration might lead to non-compliance. Multiple preparation steps and volume calculations are also among risk factors for medicine errors in children. An alternative to OLFs is the conventional solid oral dosage form (OSF), such as tablets and capsules. These offer the advantages of greater stability, easy dose selection, improved transportability, and ease of storage. They also allow the modification of drug pharmacokinetic parameters, minimizing administration frequency. Finally, OSFs are less costly than OLFs, since they are easier to develop, manufacture, transport, store, and deliver. Controlled study results suggest that the use of OSFs in children would be associated with greater acceptability by children, greater preference on the part of caregivers, and higher drug compliance than OLFs. Recent controlled studies, confirming that OSFs with an acceptable size for children (mini-tablets), should shift the current paradigm of OLFs as the reference for children's oral medicine. We lack evidence on OSF acceptability in children and its influence on drug compliance, particularly with appropriate-size OSFs for children. Further investigation on oral formulation should investigate the utilisation of OSFs in young children. Few OSFs are licensed for children under 6 years of age.

Avoiding Errors in Adult Medicine Reckless Ian Reynolds D John Newman Sally et al Avoiding Errors in Adult Medicine184pp £29.99 Wiley-Blackwell 9780470674343 0470674385

THIS BOOK is presented in three parts. The first discusses the causes of errors in adult medicine. The second looks at 34 case studies, each following the same format: a scenario, questions on what you would do at various points, expert clinical opinion, legal comment and key learning points. And the final part is concerned with the investigation of errors and the process by which errors are dealt with, including disciplinary processes, the involvement of the courts, and investigation of a doctor’s practice by the General Medical Council.

Tapping into the wisdom in the room: results from participant discussion at the 7th International Conference on Diagnostic Error in Medicine facilitated by a World Café technique.

The patient safety literature is full of exhortations to approach medical error from a system perspective and seek multidisciplinary solutions from groups including clinicians, patients themselves, as well as experts outside the traditional medical domain. The 7th annual International Conference on Diagnostic Error in Medicine sought to attract a multispecialty audience, and attempted to capture some of the conversations by engaging participants in a World Café, a technique used to stimulate discussion and preserve insight gained during the conference. We present the ideas generated in this session, discuss them in the context of psychological safety, and demonstrate the application of this novel technique.

Medical malpractice issues related to interventional radiology complications.

Medical malpractice is defined as an adverse outcome that causes injury or harm which occurs after a physician–patient relationship establishes the duty of care.1 There must be negligence by provider which is usually interpreted as failure to provide the standard of care and direct causality between negligence and outcome. Litigation is an unfortunate consequence of medical complications although in my experience, whether or not malpractice occurred is often unrelated to whether or not a lawsuit is filed. People usually file a lawsuit because of an unexpected, bad outcome, not necessarily because malpractice was committed. Errors in medicine happen commonly, fortunately, most do not result in patient harm. Clearly, a bad outcome does not necessarily indicate malpractice but most patients are not in a position to determine whether or not true malpractice has transpired. Complications are unavoidable and most complications are defensible except for a special category referred to as “res ipsa loquitur” which is loosely translated to mean “the event speaks for itself.” These are complications that are so egregious that by definition, negligence has occurred. “Never events” such as retained foreign bodies and air embolism are often referred to as “res ipsa loquitur.” Incidentally, this is different and sometimes confused with “prima facie” which simply means that the minimal amount of evidence needed to continue a case.

Study and Evaluation of Medication Errors in Medicine and Orthopedic Wards of a Tertiary Care Hospital

Aims: The main aim of the present study was to detect and evaluate the incidence, types, factors and severity of medication errors in the medicine and orthopedic wards of a tertiary care hospital. Study Design: This was a prospective and observational study. Place and Duration of Study: Department of Medicine and Orthopedic wards of Sri Adichunchanagiri Hospital and Research Centre, B.G.Nagara-571448, Karnataka, India, between June 2014 to February 2015. Methodology: The patients who satisfied inclusion and exclusion criteria were enrolled after obtaining their consent. The required data was collected in the Case Record Form and reviewed daily from the day of admission to discharge in the posted department. Different types of medication errors was identified, documented and the severity of medication error was identified by using NCC MERP guidelines. Results: A total of 200 inpatient cases from orthopedic ward and medicine ward were collected, 100 cases from each ward. In orthopedic ward, 40% patients were of 20-39 years age and in medicine ward, 48% patients were of 60-79 years age. A total of 136 and 103 medication errors were observed in orthopedic and medicine ward, among them 65% and 62% were prescription errors, 25% and 18% were administration errors, 6% and 12% were transcription errors and 4% and 8% were dispensing errors. The cause of medication errors were 64.7% and 62.1% were due to physicians, 31.6% and 30.1% were due to nurses and 3.7% and 7.8% were due to pharmacists in orthopedic and medicine ward. Majority of medication errors 68.4% and 62.1% were belonged to category-B severity in orthopedic and medicine ward respectively. Conclusion: Clinical pharmacist can play a major role in preventing medication errors by early detection. Since our system lacks a well-organize detection and reporting mechanism, Hence, as the first step we must implement a system where errors are routinely detected and reported.

Психология диагностической ошибки

Diagnostic errors in medicine occur frequently and the consequences for the patient can be severe. Cognitive errors as well as system related errors contribute to the occurrence of diagnostic error, but it is generally accepted that cognitive errors are the main contributor. The diagnostic reasoning process in medicine, is an understudied area of research. One reason is because of the complexity of the diagnostic process and therefore the difficulty to measure diagnostic errors and the causes of diagnostic error. In this paper, I discuss some of the complexities of the diagnostic process. I describe the dual-process theory, which defines two reasoning modes, 1. a fast, automatic and unconscious reasoning mode called system 1, and a slow and analytic reasoning mode called system 2. Furthermore, the main cognitive causes of diagnostic error are described.

Medicine errors can be avoided with clearer IV bag labels, research suggests

Medicine errors can be avoided with clearer IV bag labels, research suggests