OBJECTIVE: To determine the error rate for discharge coding of anal sphincter laceration at vaginal delivery in a cohort of primiparous women. METHODS: As part of the Childbirth and Pelvic Symptoms study performed by the National Institutes of Health Pelvic Floor Disorders Network, we assessed the relationship between perineal lacerations ...

Medication errors cause substantial harm to patients, and considerable cost to healthcare systems. Evidence suggests that communication plays a crucial role in the generation, management and prevention of such incidents. This review identifies how paediatric medication errors can be managed, and in particular focuses on the pathway of steps that ...

OBJECTIVE: A worrisome increase in mortality has been reported recently following the initiation of a computerized physician order entry (CPOE) system in a critically ill pediatric transport population. We tested the hypothesis that such a mortality increase did not occur after the initiation of CPOE in a pediatric population that ...

Three decades advocating the elimination of ambiguous medical notations, one of the most common, but preventable causes of medication errors, came into sharp focus in 2006 when the FDA and the Institute for Safe Medication Practices launched a comprehensive educational campaign against medical mistakes rooted in unclear abbreviations, symbols and ...

Variation between laboratories and reference sources in the units used for reporting pathology results raises the possibility of medical error. Data submitted to the RCPA Quality Assurance Programs demonstrate wide variation in the units used for reporting therapeutic drug concentrations. This potential source of medical error needs to be addressed ...

STUDY OBJECTIVE: We identify the incidence, nature, and consequences of medication errors among acutely ill and injured children receiving care in a sample of rural emergency departments (EDs). METHODS: Two pediatric pharmacists applied a medication error data collection instrument to the medical records of all critically ill children (highest triage ...

BACKGROUND: The National Haemovigilance Office has collected and analysed reports on errors associated with transfusion since 2000. A 3-year pilot research project in near-miss event reporting commenced in November 2002. MATERIALS AND METHODS: Near-miss reports from 10 hospital sites were analysed between May 2003 and May 2005. The Medical Event ...

BACKGROUND: Methamphetamine abuse has become an increasing problem in both the United States and globally with concomitant increases in adverse medical, social and environmental sequelae. Behavioral therapies have been used with some success to treat methamphetamine abusers and dependent individuals, but are not universally efficacious. Methamphetamine has a rich pharmacology ...

OBJECTIVES: To introduce otolaryngologists to proposed standards regarding allergen vial mixing, to identify clinical implications, and to recommend efforts to address the issue of vial mixing standards. STUDY DESIGN AND METHODS: A policy review. RESULTS: The Institute of Medicine report on medical errors increased awareness of medication errors, spurring efforts ...

Medication errors involving pediatric patients in the postanesthesia care unit may occur as frequently as one in every 20 medication orders and are more likely to cause harm when compared to medication errors in the overall population. Researchers examined six years of records from the MEDMARX database and used consecutive ...

BACKGROUND: Although children are at the greatest risk for medication errors, little is known about the overall epidemiology of these errors, where the gaps are in our knowledge, and to what extent national medication error reduction strategies focus on children. OBJECTIVE: To synthesise peer reviewed knowledge on children's medication errors ...

OBJECTIVE: It has been hypothesized that the error negativity (Ne or ERN) is modulated by the midbrain dopaminergic system. Thus, in a depleted dopaminergic system as seen in patients with Parkinson's disease (PD) one would expect an attenuated Ne. However, studies investigating the error negativities in medicated patients with PD ...

BACKGROUND AND PURPOSE: Medication access is crucial to secondary stroke prevention. We assessed medication access and associated barriers to care across region and time in a national sample of US stroke survivors. METHODS: Among all 5840 black or white stroke survivors aged > or =45 years responding to the National ...

We propose scalable architectures for the coherence-preserving qubits introduced by Bacon, Brown, and Whaley [Phys. Rev. Lett. 87, 247902 (2001)]. These architectures employ extra qubits providing additional degrees of freedom to the system. These extra degrees of freedom can be used to counter coupling strength errors within the coherence-preserving qubit ...

Little information is available regarding the use of computerized physician-order entry (CPOE) in the outpatient setting or the role of pharmacists in preventing prescription errors with CPOE. This study evaluated the effect of CPOE on pharmacist-intercepted prescription errors in the outpatient setting by using data collected from a retrospective survey ...

OBJECTIVE: To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated. DESIGN: ...

Medical errors may result from lapses in judgment or lack of prudent care by individual physicians, from system errors inherent in the medical-care delivery model or, more frequently, from a combination of the two. Medical error reporting is a sensitive topic for physicians, institutions, and patients. The veil of secrecy ...

Because primary data collection can be expensive, researchers are increasingly using information collected in medical administrative databases for scientific purposes. This information, however, is typically collected for reasons other than research, and many such databases have been shown to contain substantial proportions of misclassification errors. For example, many administrative databases ...

BACKGROUND: There is little published information on the level of self-reported understanding of diabetes mellitus (DM) and its treatment among elderly subjects with DM or on the association between such understanding and the likelihood of errors in the recall of medication regimens. OBJECTIVES: The primary objectives of the present study ...

INTRODUCTION: The climate within the United States is rapidly changing with respect to patient and family knowledge of medical error and their expectations of the events that should occur after an error. OBJECTIVE: This article examines the history and changing tide of medical error disclosure, reviews the limited but growing ...

PURPOSE: The purpose of this study was to compare the number and type of medication errors reported before and after the implementation of computerized prescriber order entry (CPOE); the involvement of a pharmacy resident in the CPOE implementation process will be described. METHODS: CPOE implementation in the neurosurgical intensive care ...

OBJECTIVES: To understand and classify causal factors linked to medication errors and to define opportunities for systematic changes to improve the safety of prescription medication use. Design, Setting, and PARTICIPANTS: All recipients of liver, kidney, and/or pancreas allografts followed up by an academic medical center and encountered in the acute ...

OBJECTIVES: To compare the Canadian public's view of various components of hospital performance at two points in time, and to investigate differences across provinces. METHODS: Random telephone interviews were conducted across Canada in 2001 and again in 2004. Respondents were asked to rate the importance of 10 aspects of hospital ...

BACKGROUND: Marine fish oil supplements are frequently administered with other lipid medications for treatment of hypertriglyceridemia. The efficacy of fish oil may be reduced in the presence of other lipid agents, particularly fibrates that also act as PPARalpha agonists. We therefore sought to determine the efficacy of fish-oil supplements when ...

PURPOSE: The implementation of a multidisciplinary approach to systematically decrease medication errors through the use of observation methodology and the deployment of electronic medication administration records (EMARs) and bar-coded-medication administration (BCMA) is described. SUMMARY: For a consistent and reliable approach to data collection, a direct-observation technique was used. The measurement ...

OBJECTIVE: The aim of this study was to learn about community members' definitions and types of harm from medical mistakes. METHODS: Mixed methods study using community-based participatory research (CBPR). The High Plains Research Network (HPRN) with its Community Advisory Council (CAC) designed and distributed an anonymous survey through local community ...

BACKGROUND/PURPOSE: Patient safety is an important issue in medical quality control. To our knowledge, no studies have been conducted to specifically address patient safety in surgery in Taiwan. The purposes of this study were to determine the incidence of surgical errors in Taiwan, to evaluate the effectiveness of a campaign ...

OBJECTIVE: To assess the feasibility and acceptability of obtaining data on prescribing error rates in routine practice, and presenting feedback on such errors to medical staff. SETTING: One clinical directorate of a London teaching trust. METHODS: Ward pharmacists recorded all prescribing errors identified in newly written medication orders on one ...

INTRODUCTION: Computerised physician order entry with clinical decision support system (CPOE+CDSS) is an important tool in attempting to reduce medication errors. The objective of this study was to evaluate the impact of a CPOE+CDSS on (1) the frequency of errors in ordering resuscitation (CPR) medications and (2) the time for ...

OBJECTIVES: To characterize the types of patient-related errors that lead to adverse drug events (ADEs) and identify patients at high risk of such errors. DESIGN: A subanalysis within a cohort study of Medicare enrollees. SETTING: A large multispecialty group practice. PARTICIPANTS: Thirty thousand Medicare enrollees followed over a 12-month period. ...

PURPOSE: A plan for the implementation of medication-related health information technology (HIT) in 12 critical access hospitals (CAHs) to improve safety and reduce medication errors is described. SUMMARY: Interviews were conducted to assess the status of HIT in 12 CAHs, including HIT needs and desires and barriers to HIT adoption. ...

The serotonin syndrome is an acute adverse reaction to medications that enhance serotonergic activity. The severity of cases ranges from mild to fatal. Recently, the U.S. Food and Drug Administration issued an alert that the risk of developing serotonin syndrome may be increased by the concomitant administration of triptan medications ...

OBJECTIVE: To develop a taxonomy of errors derived solely from the content of error reports using Canadian data from the Primary Care International Study of Medical Errors. DESIGN: Secondary analysis of data from a descriptive, cross-sectional, self-report survey. SETTING: Community-based family medicine clinics. PARTICIPANTS: Family physicians. INTERVENTION: Implementation of an ...

Healthcare providers typically think of patient safety in the context of preventing iatrogenic injury. Prevention of falls and medication or treatment errors is the typical focus of adverse event analyses. If healthcare providers are committed to honoring the wishes of patients, then perhaps failures to honor advanced directives should be ...

BACKGROUND: Adverse effects of medical errors have received increasing attention. Diagnostic errors account for a substantial fraction of all medical errors, and strategies for their prevention have been explored. A crucial requirement for that is better understanding of origins of medical errors. Research on medical expertise may contribute to that ...

Providing safe nursing home care is both a clinical and fiscal challenge in many countries. The fiscal realities result in the addition of other workers, such as medication technicians or aides (CMT/A), to the health care team. The purpose of this study was to determine the impact of various levels ...

BACKGROUND: At the time of transition from hospital to home, many patients are challenged by multi-drug regimens. The authors' standard patient education tool is a personalised Medication Discharge Worksheet (MDW) that includes a list of medications and administration times. Nonetheless, patient understanding, satisfaction, and safety remain suboptimal. Therefore, the authors ...

BACKGROUND: Resident duty hour limitations aim, in part, to reduce medical errors. Residents' perceptions of the impact of duty hours on errors are unknown. OBJECTIVE: To determine residents' self-reported contributing factors, frequency, and impact of hours worked on suboptimal care practices and medical errors. DESIGN: Cross-sectional survey. SUBJECTS: 164 Internal ...

standards in the use of statistics in medical research are generally low. A growing body of literature points to persistent statistical errors, flaws and deficiencies in most medical journals. in this paper we present a comprehensive review of common statistical pitfalls which can occur at different stages in the scientific ...

PURPOSE: The interrater agreement for and reliability of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index for categorizing medication errors were determined. METHODS: A letter was sent by the U.S. Pharmacopeia to all 550 contacts in the MEDMARX system user database. Participants were asked to ...

Background: To prevent medication errors in prescribing, one needs to know their types and relative occurrence. Such errors are a great cause of concern as they have the potential to cause patient harm. The aim of this study was to determine the nature and types of medication prescribing errors in ...

BACKGROUND: The Objective Structured Clinical Examination (OSCE) is an assessment tool characterized by the use of "lay" people trained to respond to questions in a standardized fashion. The learner's performance is observed and scored against a checklist of responses or behaviors. An OSCE station related to the communication and management ...

Our aim was to explore the attitudes and beliefs of healthcare professionals relating to the causes and reporting of medication errors in a UK intensive care unit. Medication errors were identified by the unit pharmacist and semi-structured qualitative interviews conducted with 13 members of staff involved with 12 errors. Interviews ...

This article unwraps the nature and source of human errors involved in Radiology, revealing unique elements of the specialty that warrant special consideration in medical malpractice cases. The authors compare these errors to negligent practices in other professions and conclude that a general concept of negligence cannot adequately address the ...

The purpose of this paper is to present a remarkable medical equipment-induced adverse event and to suggest ways to prevent similar problems. This paper uses a case study to discuss when it is necessary to renew medical equipment. The paper finds that repairing medical equipment using inappropriate parts causes severe ...

Clinical communication failures caused 60% of sentinel events reported by the Joint Commission on Accreditation of Healthcare Organizations. The difficulties of communication have been the primary cause of errors leading to patients' death. For analyzing medical error events, uncovering the patterns of clinical communication, this paper reports the design and ...

The Agency for Healthcare Research and Quality (AHRQ) recently funded the PBRN Resource Center to develop a system for reporting ambulatory medication errors. Our goal was to develop a usable system that practices could use internally to track errors. We initially performed a comprehensive literature review of what is currently ...

Neonates are highly vulnerable to medication errors because of their extensive exposure to medications in the neonatal intensive care unit (NICU), the general lack of evidence on pharmacotherapeutic interventions in neonates and the lack of neonate-specific formulations. We searched PubMed and EMBASE to identify relevant original studies published in the ...

BACKGROUND: It is widely acknowledged that many prescription drug errors occur in the ambulatory care setting and that they have serious quality of care implications. Previous research examining this issue has focused on hospitals and on individual-level factors. This study adopts an organizational perspective to assess the effects of organizational ...

The sport of boxing has been the source of much debate, with concerns about the neurological risks of participating having led to many calls to ban the sport. This review seeks to establish an evidence base for the development of boxing-related chronic traumatic encephalopathy (CTE) and to determine the relevance ...