Drug shortages may compromise patient safety: Results of a survey of the reference pharmacies of the Drug Commission of German Pharmacists

Health Policy ◽  
2018 ◽  
Vol 122 (12) ◽  
pp. 1302-1309 ◽  
Author(s):  
André Said ◽  
Ralf Goebel ◽  
Matthias Ganso ◽  
Petra Zagermann-Muncke ◽  
Martin Schulz
Keyword(s):  
Patient Safety ◽  
Drug Shortages ◽  
Compromise Patient Safety

scholarly journals A Brief Analysis of Telemetry-Related Events

2019 ◽  
pp. 42-50
Author(s):  
Elizabeth Kukielka ◽  
Kelly Gipson ◽  
Rebecca Jones
Keyword(s):  
Patient Safety ◽  
Cardiac Rhythm ◽  
Reporting System ◽  
Healthcare Providers ◽  
Steady Increase ◽  
Monitoring Equipment ◽  
Safety Reporting ◽  
Common Event ◽  
Life Threatening ◽  
Compromise Patient Safety

Successful telemetry monitoring relies on timely clinician response to potentially life-threatening cardiac rhythm abnormalities. Breakdowns in the processes and procedures associated with telemetry monitoring, as well as improperly functioning telemetry monitoring equipment, may lead to events that compromise patient safety. An analysis of reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from January 2014 through December 2018 identified 558 events specifically involving interruptions or failures associated with telemetry monitoring equipment or with the healthcare providers responsible for setting up and maintaining proper functioning of that equipment. The analysis highlighted a steady increase in the quantity of event reports associated with telemetry monitoring submitted to PA-PSRS. User errors accounted for nearly half (47.1%, 263 of 558) of events in the analysis. The most common event subtypes included: errors involving batteries in telemetry monitoring equipment (14.0%); errors in which patients were not connected to telemetry monitoring equipment as ordered (12.9%); errors involving broken, damaged, or malfunctioning telemetry monitoring equipment (10.9%); and errors in which patients were connected to the wrong telemetry monitoring equipment (9.0%).

scholarly journals Improving patient safety through education: how visual recognition skills may reduce medication errors on surgical wards

2011 ◽  
Vol 2 (1) ◽  
pp. 1
Author(s):  
Christopher R. Davis ◽  
Edward C. Toll ◽  
Paul M. Bevis ◽  
Helena P. Burden
Keyword(s):  
Patient Safety ◽  
Medication Errors ◽  
Undergraduate Education ◽  
Visual Recognition ◽  
Healthcare Professionals ◽  
Postgraduate Training ◽  
Response Rate ◽  
Recognition Rate ◽  
Compromise Patient Safety ◽  
The Uk

Medication errors compromise patient safety and cost £500m per annum in the UK. Patients who forget the name of their medication may describe the appearance to the doctor. Nurses use recognition skills to assist in safe administration of medications. This study quantifies healthcare professionals’ accuracy in visually identifying medications. Members of the multidisciplinary team were asked to identify five commonly prescribed medications. Mean recognition rate (MRR) was defined as the percentage of correct responses. Dunn’s multiple comparison tests quantified inter-professional variation. Fifty-six participants completed the study (93% response rate). MRRs were: pharmacists 61%; nurses 35%; doctors 19%; physiotherapists 11%. Pharmacists’ MRR were significantly higher than both doctors and physiotherapists (P<0.001). Nurses’ MRR was statistically comparable to pharmacists (P>0.05). The majority of healthcare professionals cannot accurately identify commonly prescribed medications on direct visualization. By increasing access to medication identification resources and improving undergraduate education and postgraduate training for all healthcare professionals, errors may be reduced and patient safety improved.

Implementation of the TeamSTEPPS Curriculum With Baccalaureate Nursing and Social Work Students Utilizing Student Trainers: A Qualitative and Quantitative Study

2020 ◽  
Vol 26 (3) ◽  
pp. e63-e69
Author(s):  
Susan L. Huehn ◽  
Mary Beth Kuehn ◽  
Genesis M. Fukunaga Luna Victoria
Keyword(s):  
Patient Safety ◽  
Social Work ◽  
Nursing Students ◽  
Training Program ◽  
Communication Skills ◽  
Social Work Students ◽  
Skills Training ◽  
Clinical Experiences ◽  
Qualitative And Quantitative ◽  
Compromise Patient Safety

Nursing and social work education programs are seeking innovative ways to prepare students to function as collaborative members of interprofessional teams upon graduation. Communication is a key linked to a decrease in medical errors, which compromise patient safety. In response to nursing students' concerns about clinical experiences in which they had witnessed poor communication with the potential to jeopardize patient care, faculty members identified a communication skills training program designed to improve team performance. Senior nursing and social work students at the beginning of their last semester of school were trained in selected modules of the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training program and subsequently trained their student colleagues. The goal was to emphasize communication skills and strategies in a sustainable student trainer model. Qualitative and quantitative data about participant experiences revealed significant improvement in teamwork attitudes and communication skills following the training.

DOES RESIDENCY TRAINING COMPROMISE PATIENT SAFETY?

1990 ◽  
Vol 70 (Supplement) ◽  
pp. S36 ◽  
Author(s):  
R. Brown ◽  
H. R. Vijayakumar
Keyword(s):  
Patient Safety ◽  
Residency Training ◽  
Compromise Patient Safety

scholarly journals Reform Workplace Practices of Chain Pharmacies to Reduce Medication Errors

2020 ◽  
Vol 17 (02) ◽  
Author(s):  
Crystal D. Grant ◽  
Daniel J. Desautels ◽  
Jennifer Puthota
Keyword(s):  
Patient Safety ◽  
Data Collection ◽  
Health Effects ◽  
Medication Errors ◽  
Working Conditions ◽  
Pharmacy Practice ◽  
Quality Metrics ◽  
Adverse Health Effects ◽  
Compromise Patient Safety ◽  
Minimal Data

Pharmacists employed by chain pharmacies have raised concerns over corporate-mandated practices that compromise patient safety. Harsh working conditions and the pressure to meet mandated quality metrics have increased the likelihood of medication errors. Complications associated with medication errors exceed $40 billion and cause adverse health effects for hundreds of thousands of Americans annually. Despite their ubiquity, chain pharmacies face varying regulations as state pharmacy boards dictate individual statewide policies. There is minimal data collection on pharmacy practices and state pharmacy boards do not require pharmacies to report errors. We recommend Congress pass a bill mirroring the Illinois Pharmacy Practice Act to improve pharmacists’ working conditions and mandate data collection on medication errors nationwide.

scholarly journals Classification of Failures in the Perception of Conversational Agents (CAs) and Their Implications on Patient Safety

2021 ◽  
Author(s):  
Haris Aftab ◽  
Syed Hammad Hussain Shah ◽  
Ibrahim Habli
Keyword(s):  
Patient Safety ◽  
Insulin Dose ◽  
Conversational Agents ◽  
User Interactions ◽  
Safety Issues ◽  
Healthcare Settings ◽  
Medication Dose ◽  
Compromise Patient Safety ◽  
Administrative Tasks

The use of Conversational agents (CAs) in healthcare is an emerging field. These CAs seem to be effective in accomplishing administrative tasks, e.g. providing locations of care facilities and scheduling appointments. Modern CAs use machine learning (ML) to recognize, understand and generate a response. Given the criticality of many healthcare settings, ML and other component errors may result in CA failures and may cause adverse effects on patients. Therefore, in-depth assurance is required before the deployment of ML in critical clinical applications, e.g. management of medication dose or medical diagnosis. CA safety issues could arise due to diverse causes, e.g. related to user interactions, environmental factors and ML errors. In this paper, we classify failures of perception (recognition and understanding) of CAs and their sources. We also present a case study of a CA used for calculating insulin dose for gestational diabetes mellitus (GDM) patients. We then correlate identified perception failures of CAs to potential scenarios that might compromise patient safety.

scholarly journals Analysis of notifications of adverse events in a private hospital

2019 ◽  
Vol 18 (3) ◽  
pp. 314-343
Author(s):  
Alcides Viana de Lima Neto ◽  
Fernanda Antunes da Silva ◽  
Genilza Maria De Oliveira Lima Brito ◽  
Tatiana Mari A Nóbrega Elias ◽  
Bruna Aderita Cortez de Sena ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Private Hospital ◽  
Medication Administration ◽  
Contributing Factors ◽  
Event Notification ◽  
Adverse Incident ◽  
Compromise Patient Safety ◽  
Current Context ◽  
Human Failure

Introducción: La seguridad del paciente, en el contexto actual, pasó a ser investigada en los diversos campos de la salud, con el objetivo de reducir la incidencia de daños y eventos adversos a los pacientes. Objetivo: Identificar y analizar los eventos adversos que comprometen la seguridad del paciente durante la asistencia de enfermería en un hospital privado. Métodos: Investigación exploratoria, documental y retrospectiva. El instrumento de recolección de datos fue el informe de notificación de eventos adversos utilizado por el hospital compuesto por cuestiones abiertas y cerradas. Resultados: Se analizaron 262 informes de notificación de eventos adversos / incidentes que ocurrieron en el período de 2015 a 2016. Se demuestra que los factores contribuyentes para la ocurrencia de los eventos adversos fueron causados por fallo humano. Del total de formularios analizados, 161 (61,83%) indicaron descuido y distracción. La omisión se destacó con 11 (4,20%) casos. La falta de atención con el paciente propició 116 (44,27%) errores en la administración de medicamentos, 46 (17,56%) fallos durante la digitación y transcripción de la prescripción médica y 35 (13,36%) fallos en la asistencia. Conclusión: Se percibe que los incidentes son causados por factores humanos y de posible reversión. Cuando son investigados, pueden ser minimizados, lo que contribuye a la calidad y seguridad en el cuidado al paciente. Introduction: patient safety, in the current context, began to be investigated in the different health fields, aiming to reduce the incidence of damages and adverse events to patients. Objective: to identify and analyze adverse events that compromise patient safety during nursing care in a private hospital. Methods: exploratory, documentary and retrospective research. The instrument of data collection was the report of adverse event notification used by the hospital composed of open and closed questions. Results: the researchers analyzed 262 reports of adverse/incident events that occurred in the period 2015 to 2016. The contributing factors for the occurrence of adverse events were caused by human failure. Of the total number of forms analyzed, 161 (61.83%) reported carelessness and distraction. The omission was highlighted with 11 (4.20%) cases. The lack of attention with the patient led to 116 (44.27%) errors in medication administration, 46 (17.56%) failures during the typing and transcription of the medical prescription and 35 (13.36%) failures in care. Conclusion: the incidents are caused by human factors, with possible reversion. When investigated, they can be minimized, which contributes to quality and safety in patient care. Introdução: A segurança do paciente, no contexto atual, passou a ser investigada nos diversos campos da saúde, com o objetivo de reduzir a incidência de danos e eventos adversos aos pacientes. Objetivo: Identificar e analisar os eventos adversos que comprometem a segurança do paciente durante a assistência de enfermagem em um hospital privado. Métodos: Pesquisa exploratória, documental e retrospectiva. O instrumento de coleta de dados foi o relatório de notificação de eventos adversos utilizado pelo hospital composto por questões abertas e fechadas. Resultados: Analisaram-se 262 relatórios de notificação de eventos adversos/incidentes que ocorreram no período de 2015 a 2016. Demonstra-se que o fatores contribuintes para a ocorrência dos eventos adversos foram causados por falha humana. Do total de formulários analisados, 161 (61,83%) apontaram descuido e distração. A omissão se destacou com 11 (4,20%) casos. A falta de atenção com o paciente propiciou 116 (44,27%) erros na administração de medicamentos, 46 (17,56%) falhas durante a digitação e transcrição da prescrição médica e 35 (13,36%) falhas na assistência. Conclusão: Percebe-se que os incidentes são causados por fatores humanos e de possível reversão. Quando investigados, podem ser minimizados, o que contribui para a qualidade e segurança no cuidado ao paciente.

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