High Incidence Of Errors Research Articles

Incidence of immunization errors in the state of Minas Gerais, Brazil: a cross-sectional study, 2015-2019.

To evaluate the incidence of immunization errors in the public health service of the state of Minas Gerais, Brazil. This was a cross-sectional study, based on errors reported on the National Immunization Program Information System between 2015 and 2019. A descriptive analysis and calculation of the incidence for the state's health macro-regions were performed. A total of 3,829 notifications were analyzed. Children younger than 1 year old were the most affected (39.1%) and the intramuscular route accounted for 29.4% of the errors. The most frequently reported error was administration of vaccines outside minimum and maximum recommended ages (37.7%). There was a higher incidence of errors in Vale do Aço (26.5/100,000) and Triângulo do Norte (22.6/100,000) macro-regions. Immunization errors showed a heterogeneous incidence among the macro-regions of the state of Minas Gerais, between 2015-2019, and the administration of vaccines outside minimum and maximum recommended ages was the most frequently reported error.

The Essential Steps of Medication Administration Practices Project medication administration improvement practices among acute inpatients in a tertiary hospital

The current project aimed to conduct an audit of nursing medication administration practices, to implement evidence-based best practice recommendations and assess the effectiveness of these changes in maximizing medication administration safety and reducing the risks of adverse incidents across 10 wards/units in a large tertiary hospital.Medications are the most common treatment used in healthcare. Because they are so commonly used, medications are associated with a higher incidence of errors and adverse events than other healthcare interventions. Nurses are primarily involved in the administration of medications to patients and this duty is an important aspect of professional practice. The Australian Commission on Safety and Quality in Healthcare has recognized medication safety as a National Standard, thus reinforcing its importance.The project used the JBI's Practical Application of Clinical Evidence System and Getting Research into Practice audit tool for promoting change in healthcare practice. A baseline audit of 200 observations of medication administration was conducted and measured against eight best practice recommendations, followed by the implementation of targeted strategies and follow-up audits.The baseline audit revealed deficits between current practice and best practice in three of the eight criteria. Identification of barriers for implementation of medication administration best practice criteria were made by the project team and reflective practice and ward/unit led strategies were implemented. There were improved or sustained outcomes across all best practice criteria in the follow-up audits.The findings showed how audit may be used to promote best practice in healthcare and that reflective practice and front-line led strategies can have a positive impact on clinical practice. Some of the measured criteria did not reach 100%, leaving room for improvement; however, by the end of the project attitudes towards medication administration had been 'transformed' from a passive, routine 'must do' task, to an active process with a focus on safety and patient/carer engagement. Future audits are planned to ensure sustainability.

Tongue-palate contact for nasal versus oral stops in speakers with repaired cleft palate

ABSTRACTMost previous studies of speech disorders associated with cleft palate have reported a higher incidence of errors for oral stops, fricatives and affricates compared to nasal stops. However, the results of a recent ultrasound study have raised the possibility that errors affecting nasal consonants might not be as rare as originally thought. A review of the electropalatography (EPG) literature on cleft palate speech has also shown that atypical tongue-palate contact patterns can occur during nasal consonants and that nasal and oral stops are often produced with similar atypical lingual gestures. Therefore, this study investigated the production of nasal stops (/n/and/ŋ/) and the homorganic oral stops (/t/,/d/and/k/,/ɡ/respectively) in eight children with repaired cleft palate using perceptual judgements and evaluation of tongue-palate contact patterns. Results of the perceptual judgements support the findings in the literature that there was a higher per cent phoneme correct for the alveolar nasal (about 90%) than for the oral stops (60–70%). However, there was a low per cent phoneme correct for the velar nasal (about 50%) and the per cent correct as determined by the EPG data was lower than those based on perceptual judgements. Two children showed similar atypical articulatory gestures for the oral and nasal alveolar stops. We discuss the possibility that the nasal errors may be of phonemic as opposed to phonetic origin. The results underscore the importance of considering the phonological dimension of production when assessing the speech of children in this clinical group.

Assessment of Emergency Department Antibiotic Discharge Prescription Dosing Errors for Pediatric Patients in a Community Hospital Health System

We quantify and describe emergency department antibiotic discharge prescription dosing errors for pediatric patients in a community hospital health system. This was a retrospective chart review evaluating emergency department discharge prescriptions written between July 1, 2014, and June 30, 2015. Pediatric patients who received a prescription for an oral antibiotic were included in error analysis if they had a weight updated in the electronic medical record during the encounter. We used a predefined threshold of +10% variance from the recommended dose to quantify error. Prescriber, environmental, and antibiotic specific data were also collected to identify variables associated with high incidence of error. Among the 1934 prescriptions included in our error analysis, we detected 776 (40%) dosing errors. Of the prescriptions reviewed, 288 (15%) contained an overdosing error and 488 (25%) contained an underdosing error. There were 208 underdosing errors written for amoxicillin to treat acute otitis media. These errors represented 43% of the total underdosing errors and had a greater magnitude of variance from the recommended dose compared with overall underdosing errors. Underdosing of amoxicillin in acute otitis media was a dosing error that occurred frequently throughout our community health system. Further research is needed to identify the clinical impact these errors have on pediatric patients.

Nurse Perceptions and Safety Practices of the Carpuject Cartridge System.

Injectable medications have been found to be associated with a higher incidence of errors than with other medication preparations. Carpuject syringe systems have been implemented to protect patients and improve safety; however, an overall lack of knowledge of the device was discovered. The purpose of this study, using a pre/postsurvey design, was to investigate nursing knowledge of and practices with the prefilled Carpuject syringe system and narcotic dilution practices before and after multidisciplinary interventions. Statistically significant differences were found before and after interventions.

A decade of burn unit experience with Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis: Clinical pathological diagnosis and risk factor awareness

Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) is a rare and often fatal spectrum of mucocutaneous diseases usually attributable to severe adverse drug reactions. Burn units are referral centers for patients at the most extreme end of the disease continuum. Our burn center admits a much higher percentage of TEN (>30% BSA) cases than reported in most prior reviews. The purpose of this study was to analyze the diagnostic and prognostic value of variables collected on referred SJS/TEN patients. We retrospectively analyzed 94 patients admitted to our unit with a presumptive SJS/TEN diagnosis made in most cases by the referring center. Most of the diagnoses were clinical. Fifty of the 94 patients underwent biopsy when the clinical diagnosis was questionable. Of the 50 patients who underwent biopsy, 18 (36%) received an alternative diagnosis. Analysis was therefore limited to 76 patients, i.e. 44 patients felt to have firm clinical diagnoses plus 32 patients with diagnoses confirmed by biopsy. Mean age was 54.3 years (17–93) and overall gender ratio was 43 F vs. 33 M (56.6% vs. 43.4%). Mean LOS was 15.2 days (1–48) and overall mortality was 23.7% (18/76). Univariate analysis revealed percent body surface area (%BSA) did not show statistically significant association with mortality. Histopathological correlation for diagnosis is not standardized across institutions worldwide. Due to challenges in the diagnosis of SJS/TEN and the high incidence of error in clinical diagnosis, it is recommended that all patients with presumed SJS/TEN receive skin biopsies with H&E and direct immunofluorescence. We propose a diagnostic approach in order to address this need. Lack of association between %BSA and mortality suggests that all biopsy-proven SJS/TEN cases belong in specialty centers due to the unstable nature of the disease and risk for rapid progression.

Influence of planning time and treatment complexity on radiation therapy errors

PurposeRadiation treatment planning is a complex process with potential for error. We hypothesized that shorter time from simulation to treatment would result in rushed work and higher incidence of errors. We examined treatment planning factors predictive for near-miss events. Methods and materialsTreatments delivered from March 2012 through October 2014 were analyzed. Near-miss events were prospectively recorded and coded for severity on a 0 to 4 scale; only grade 3-4 (potentially severe/critical) events were studied in this report. For 4 treatment types (3-dimensional conformal, intensity modulated radiation therapy, stereotactic body radiation therapy [SBRT], neutron), logistic regression was performed to test influence of treatment planning time and clinical variables on near-miss events. ResultsThere were 2257 treatment courses during the study period, with 322 grade 3-4 near-miss events. SBRT treatments had more frequent events than the other 3 treatment types (18% vs 11%, P = .04). For the 3-dimensional conformal group (1354 treatments), univariate analysis showed several factors predictive of near-miss events: longer time from simulation to first treatment (P = .01), treatment of primary site versus metastasis (P < .001), longer treatment course (P < .001), and pediatric versus adult patient (P = .002). However, on multivariate regression only pediatric versus adult patient remained predictive of events (P = 0.02). For the intensity modulated radiation therapy, SBRT, and neutron groups, time between simulation and first treatment was not found to be predictive of near-miss events on univariate or multivariate regression. ConclusionsWhen controlling for treatment technique and other clinical factors, there was no relationship between time spent in radiation treatment planning and near-miss events. SBRT and pediatric treatments were more error-prone, indicating that clinical and technical complexity of treatments should be taken into account when targeting safety interventions.

Spreadsheets and the Violence of Forms: Tracking Organisational and Domestic Use

Spreadsheets and the Violence of Forms: Tracking Organisational and Domestic Use

English Abstracts in Open Access Translation Studies Journals in Spain (2011-12)

In this study of 197 abstracts from the ten most prestigious open access Translation Studies journals published in Spain between 2011-12, 73 of 197 abstracts (37%) were found to contain a total of 128 errors (75 grammatical, 42 vocabulary-related and 11 typographical). Three “risk factors” were suspected to correlate with higher error incidence (&gt;40% error rate), namely: 1. when abstracts do not conform to the author's guidelines for language and length; 2. when abstracts appear in monographic issues or dossiers within issues; and 3. when abstracts appear in journals published only electronically. A higher error incidence was found to correspond with those journals that presented all three risks (3/4 (75%). A correspondence between high incidence of error and individual risk factors was also found: 67% of electronic only published journals, 71% of monographic guest-edited journals and 57% of journals with length non-compliance had higher error incidences. Several recommendations for journal editors and abstract authors are provided.

Evidence of frequent dosing errors in paediatrics and intervention to reduce such prescribing errors

Drug prescribing is an essential part of inpatient care, and prescription errors/omissions have the potential to lead to disastrous consequences. Paediatric inpatient prescribing is particularly sensitive to error due to the weight-adjusted dosing of many medications prescribed in the acute setting. Previous studies have described a high incidence of error in adult drug chart completion, although no studies to date have assessed the error seen in the paediatric setting or accuracy of weight-adjusted dosing. Our objective was to determine the degree of error seen in paediatric drug prescribing for patients admitted under the care of oral and maxillofacial surgery and to explore practical and accessible methods through which error can be reduced. We retrospectively evaluated inpatient drug charts to assess the prescribing practices seen for patients admitted under the care of oral and maxillofacial surgery in an NHS children's hospital and compared these findings against established hospital standards. The study also examined the distribution and variability of weight-adjusted dose prescribing in an attempt to set targets for auditing improvements following the implementation of changes. Prescriptions were completed by a combination of doctors from maxillofacial and anaesthetic teams, with similar error rates seen in both specialties. 13% of drug charts contained one or more errors in frequency prescribing. For weight-adjusted drugs, a median under-dosage of -5·4% was noted, with an IQR of -12 to -0·6. Our study has confirmed that errors are common both in the manual completion of paediatric prescription charts and in the calculation of weight-adjusted doses. We conclude that inaccuracies in prescription chart completion are a frequent occurrence and that dosage and frequency-prescribing errors may potentially act synergistically to create a significant disparity between the recommended and actual amount of drug that is delivered. Our study demonstrates a clear bias towards under-prescribing weight-adjusted doses which may be contributing to reduced efficacy of analgesia, among other drugs. Simple methods can be implemented on a specialty basis to improve the accuracy of both drug chart completion and weight-adjusted dosing.

Focus assessed transthoracic echocardiography (FATE) to diagnose pleural effusions causing haemodynamic compromise

The clinical assessment of patients with respiratory and circulatory problems can be complex, time consuming and have a high incidence of error. Bedside transthoracic ultrasound (US) is a useful adjunctive test in the evaluation of acutely unstable patients. This case series describes the use of the Focus Assessed Transthoracic Echocardiography (FATE) protocol to diagnose unsuspected pleural collections of fluid and how drainage significantly contributes to the haemodynamic improvement seen in these patients.

Hope modifies the association between burnout and self-perceived medical errors among practising physicians: implications for person-centered medicine

Rationale, aims and objectives: Hope is an important resource that influences an individual’s ability to cope with stressful situations. The objective of this study is to evaluate the association of medical errors with burnout and hope among practising physicians using validated metrics.Method: Participants were physicians who had already completed residency training and were working in hospital settings (N=1054). Surveys included self-assessment of medical errors and validated Burnout Scale (depersonalization [DP] and emotional exhaustion [EE]) and Herth Hope Index. Frequency of self-perceived medical errors was recorded as the principal outcome measure.Results: A total of 716 errors were reported in 1054 physician-years. We observed a significant association between the burnout EE, DP domain score and reporting an error; compared with the lowest tertile category, IRRs of self-perceived medical errors of physicians in the highest category were 1.40 (95%CI, 1.16–1.68) and 1.37 (95%CI, 1.15–1.63) respectively, for EE and DP. We did not find a significant association between the hope score and self-perceived medical errors. In stratified analysis by hope score, among physicians with a low hope score, those who experienced higher burnout reported higher incidence of errors; physicians with high hope scores did not report high incidences of errors, even if they experienced high burnout.Conclusions: Self-perceived medical errors exhibited a strong association with physicians’ personal wellbeing: burnout was strongly associated with self-perceived errors. However, this association was modified when physicians felt hope. These results have immediate implications for the practice of person-centered medicine. In order to practise PCM effectively, the health of the person of the doctor is as important as the health of the person of the patient.

Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience

BackgroundIntravenous medication administrations have a high incidence of error but there is limited evidence of associated factors or error severity.ObjectiveTo measure the frequency, type and severity of intravenous administration errors...

Drug administration errors - time for national action

these include educating and raising awareness about medication safety, reading and re-reading labels on drug ampoules, checking the ampoule label with a second person or device (e.g. bar code reader), labelling all syringes in theatre, adhering to the international standard of colour-coded syringe labels, improving the organisation of drug drawers and work space, informing anaesthetists of new formulations or packaging of drugs, and establishing a mechanism for reporting and reviewing errors. In this issue of the SAMJ, Labuschagne et al. report on errors in drug administration by anaesthetists in public hospitals in the Free State province. 11 They confirm the problem of drug administration errors in anaesthesia, with nearly 40% of respondents admitting to making a drug administration error at some stage in their career. Their investigation, which polled full-time and occasional anaesthetic providers, supports the 90% incidence of responders reporting errors in previous South African surveys. 12,13 An expected finding in surveys of this nature is that a longer, full-time career in the specialty is more likely to be associated with a higher incidence of errors. This type of survey is useful to measure the occurrence of uncommon but potentially severe consequences, as it measures errors in very large numbers of cases, but lacks a denominator. 14

Creating and Evaluating a Data-Driven Curriculum for Central Venous Catheter Placement

Central venous catheter placement is a common procedure with a high incidence of error. Other fields requiring high reliability have used Failure Mode and Effects Analysis (FMEA) to prioritize quality and safety improvement efforts. To use FMEA in the development of a formal, standardized curriculum for central venous catheter training. We surveyed interns regarding their prior experience with central venous catheter placement. A multidisciplinary team used FMEA to identify high-priority failure modes and to develop online and hands-on training modules to decrease the frequency, diminish the severity, and improve the early detection of these failure modes. We required new interns to complete the modules and tracked their progress using multiple assessments. Survey results showed new interns had little prior experience with central venous catheter placement. Using FMEA, we created a curriculum that focused on planning and execution skills and identified 3 priority topics: (1) retained guidewires, which led to training on handling catheters and guidewires; (2) improved needle access, which prompted the development of an ultrasound training module; and (3) catheter-associated bloodstream infections, which were addressed through training on maximum sterile barriers. Each module included assessments that measured progress toward recognition and avoidance of common failure modes. Since introducing this curriculum, the number of retained guidewires has fallen more than 4-fold. Rates of catheter-associated infections have not yet declined, and it will take time before ultrasound training will have a measurable effect. The FMEA provided a process for curriculum development. Precise definitions of failure modes for retained guidewires facilitated development of a curriculum that contributed to a dramatic decrease in the frequency of this complication. Although infections and access complications have not yet declined, failure mode identification, curriculum development, and monitored implementation show substantial promise for improving patient safety during placement of central venous catheters.

Teaching of medical pharmacology: The need to nurture the early development of desired attitudes for safe and rational drug prescribing

Pharmacology, as a basic medical science discipline, provides the scientific basis of therapeutics, i.e. the scientific foundation for safe and rational prescribing of drugs. The public, lay media, and the medical profession have raised serious concerns over the high incidence of errors of drug prescribing which compromise patient safety, including death of some patients, attributed mainly to inadequate teaching of medical pharmacology and, consequently, to medical graduates lacking skills in safe and effective drug prescribing. There is also overwhelming evidence that the pervasive and prevalent doctor–drug industry relationships have a strong influence over the prescribing habits and drug education of doctors. The British Pharmacological Society and American Association of Medical Colleges have crafted some insightful guidelines, including the learning of desired attitudes, for designing a medical pharmacology curriculum aimed at enhancing patient safety. This article will critically review the major issues relating to errors of drug prescribing, including the need to nurture the early development of desired attitudes which foster safe and rational drug prescribing. A simple educational approach, using a task analysis of drug prescribing, is applied to identify desired attitudes which should be incorporated into a basic pharmacology course for medical students in the twenty-first century.

Multimodal multidisciplinary standardization of perioperative care: still a long way to go

The complexity of the perioperative care process has resulted in a suboptimal use of resources, quality problems and a relatively high incidence of errors. In an attempt to optimize resources, patient safety, and quality, multimodal, multidisciplinary standardization of the care process has become an increasingly recognized goal. The anaesthesiologist as perioperative clinician plays a pivotal role in the development and implementation of standardized perioperative care. Historically, however, a significant portion of perioperative care has relied upon anecdotal information that represents an amalgam of any individual anaesthesiologist's collective influences and experiences. Current status of standardized perioperative care and different factors that influence successful implementation of guidelines, fast track surgery programs and clinical pathways are described. Although recent literature indicates that standardization of perioperative care improves efficiency, quality, and patient satisfaction, implementation of standardized care is difficult since resistance is still enormous.

Electronic Prescribing Reduced Prescribing Errors in a Pediatric Renal Outpatient Clinic

To assess the effect of an electronic prescribing (EP) system on the incidence and type of prescribing errors and the number of error-free visits. This was a before-and-after study conducted in a nephrology outpatient clinic at an acute tertiary care pediatric hospital. A total of 520 patients had 2242 items prescribed on 1141 prescriptions during the study period. The overall prescribing error rate was 77.4% (95% confidence interval [CI] = 75.3% to 79.4%) for handwritten items and 4.8% (95% CI = 3.4% to 6.7%) with EP. Before EP, 1153 (73.3%; 95% CI = 71.1% to 75.4%) items were missing essential information, and 194 (12.3%; 95% CI = 10.8% to 14%) were judged illegible. After EP, only 9 (1.4%; 95% CI = 0.7% to 2.6%) items were missing essential information, and illegibility errors were eliminated. The number of patient visits that were error-free increased from 21% to 90% (69% difference; 95% CI = 64% to 73.4%) after the implementation of EP. There was a high incidence of errors using handwritten prescriptions in the outpatient setting, with an overall error rate of 77.4%. EP significantly reduced errors related to completeness of prescriptions and eliminated legibility related errors.

Spoken language samples of New Zealand children in conversation and narration

A New Zealand (NZ) database has been created comprising conversational and narrative spoken language samples from 268 children aged between 4;5 and 7;6 years. This paper addresses several questions related to the development and validation of the database and provides a comparison of this NZ database with an American database of language samples. Analyses of the spoken language samples contained in the database revealed a clear developmental trend of increasing syntactic complexity, semantic diversity and verbal productivity with increasing age of the participants. In addition, elicitation context for the language samples had a significant impact on language production measures obtained. The narrative language sampling contexts elicited more syntactically complex language samples. To ascertain if the New Zealand database is useful in identifying children with language impairment, oral narrative transcripts from 21 children with identified reading comprehension difficulties and mild spoken language impairment were compared to the database. The results indicated that the database was sensitive to language impairment. These children showed a much higher incidence of errors at word-level and generally produced shorter sentences compared to the language samples in the database. Comparisons between the NZ and American databases of language samples revealed that six-year-old NZ children showed stronger expressive language skills than the American children.

Phosphorylation of the Mitotic Regulator Protein Hec1 by Nek2 Kinase Is Essential for Faithful Chromosome Segregation

Hec1 (highly expressed in cancer) plays essential roles in chromosome segregation by interacting through its coiled-coil domains with several proteins that modulate the G(2)/M phase. Hec1 localizes to kinetochores, and its inactivation either by genetic deletion or antibody neutralization leads to severe and lethal chromosomal segregation errors, indicating that Hec1 plays a critical role in chromosome segregation. The mechanisms by which Hec1 is regulated, however, are not known. Here we show that human Hec1 is a serine phosphoprotein and that it binds specifically to the mitotic regulatory kinase Nek2 during G(2)/M. Nek2 phosphorylates Hec1 on serine residue 165, both in vitro and in vivo. Yeast cells are viable without scNek2/Kin3, a close structural homolog of Nek2 that binds to both human and yeast Hec1. When the same yeasts carry an scNek2/Kin3 (D55G) or Nek2 (E38G) mutation to mimic a similar temperature-sensitive nima mutation in Aspergillus, their growth is arrested at the nonpermissive temperature, because the scNek2/Kin3 (D55G) mutant binds to Hec1 but fails to phosphorylate it. Whereas wild-type human Hec1 rescues lethality resulting from deletion of Hec1 in Saccharomyces cerevesiae, a human Hec1 mutant or yeast Hec1 mutant changing Ser(165) to Ala or yeast Hec1 mutant changing Ser(201) to Ala does not. Mutations changing the same Ser residues to Glu, to mimic the negative charge created by phosphorylation, partially rescue lethality but result in a high incidence of errors in chromosomal segregation. These results suggest that cell cycle-regulated serine phosphorylation of Hec1 by Nek2 is essential for faithful chromosome segregation.