Learning from near misses: Addressing nursing chemotherapy verification fatigue.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 70-70
Author(s):  
Meghan Shea ◽  
Aya Sato-DiLorenzo ◽  
Danielle Wright ◽  
Erika Coletti ◽  
Michael Carvalho ◽  
...  
Keyword(s):  
Processing Time ◽  
Near Miss ◽  
Near Misses ◽  
Outpatient Chemotherapy ◽  
Survey Response Rate ◽  
Chemotherapy Infusion ◽  
Pre Treatment ◽  
Verification Process ◽  
Recent Patient ◽  
Common Barriers

70 Background: Administration of chemotherapy is high-risk, requiring multiple safety checks, including pre-treatment laboratory value verification by nursing. A recent series of near misses in our event reporting system highlighted that nurses verified chemotherapy orders with pending pre-treatment or abnormal labs, such as grade 2 hyperbilirubinemia and grade 4 neutropenia. Such laboratory results would normally require holding or modifying planned treatment doses. Methods: Nurses treating patients in the outpatient chemotherapy infusion units were surveyed regarding barriers to pre-treatment lab verification. A team of clinicians, nurses, and pharmacists outlined a process map of the order verification process from acknowledging patient assignment and looking at patient oncologic history to sending the physician order to pharmacy. Pharmacists collected baseline data by tracking near-miss incidents. Results: The survey response rate of outpatient treatment nurses was 18 of 32 (56%). Nurses ranked inconsistent notation of treatment criteria in orders, long lab processing time, and patient frustration with a long wait as the most common barriers to lab verification. At baseline, in six non-consecutive weeks from August-October 2016, 31 of 947 (3%) orders were inappropriately verified by nursing in which pre-treatment lab results were pending or lab results did not meet parameters in the chemotherapy order. The team’s aim is by February 1, 2017, to reduce the number of chemotherapy orders sent to pharmacy without proper lab verification by 50%. Conclusions: Chemotherapy verification fatigue, specifically pre-treatment lab near misses, was identified as an area for improvement from recent patient safety reports. Barriers for nurses include inconsistent notation of treatment criteria in orders, long lab processing time, and patient frustration with a long wait. Interventions are underway to improve nursing adherence to pre-treatment lab verification.

scholarly journals Public Roads as Places of Interspecies Conflict: A Study of Horse-Human Interactions on UK Roads and Impacts on Equine Exercise

Animals ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. 1072
Author(s):  
Danica Pollard ◽  
Tamzin Furtado
Keyword(s):  
Near Miss ◽  
Online Questionnaire ◽  
Near Misses ◽  
Logistic Regression Models ◽  
Emotional Management ◽  
The Road ◽  
Human Interactions ◽  
Road Users ◽  
Conflict Risk ◽  
The Individual

Real or perceived traffic risk is a significant barrier to walking and cycling. To understand whether similar barriers influence equestrians, this study obtained exercise behaviours, road use and experiences of road-related incidents from UK equestrians (n = 6390) via an online questionnaire. Multivariable logistic regression models were used to identify factors associated with road use and experiencing a near-miss or injury-causing incident in the previous year. Content analysis identified themes around equestrians’ decisions not to use roads. Our results show that most equestrians (84%) use roads at least once weekly, and in the previous year, 67.7% had a near-miss and 6.1% an injury-causing incident. Road use differs regionally, with exercise type and off-road route availability. Road-using equestrians covered greater daily distances and were younger. However, younger equestrians were at higher risk of near-misses. Respondents’ decisions not to use roads were based on individualised risk assessments arising from: the road itself, perceptions of other road users, the individual horse and the handler’s own emotional management. Roads were perceived as extremely dangerous places with potentially high conflict risk. Injury-causing incidents were associated with increasing road-use anxiety or ceasing to use roads, the proximity of off-road routes, having a near-miss and type of road use. Targeted road-safety campaigns and improved off-road access would create safer equestrian spaces.

scholarly journals A Generalized Structural Equation Model Approach to Long Working Hours and Near-Misses among Healthcare Professionals in Japan

2021 ◽  
Vol 18 (13) ◽  
pp. 7154
Author(s):  
Tatsuhiko Anzai ◽  
Takashi Yamauchi ◽  
Masaki Ozawa ◽  
Kunihiko Takahashi
Keyword(s):  
Indirect Effects ◽  
Structural Equation ◽  
Healthcare Professionals ◽  
Sleep Problems ◽  
Working Hours ◽  
Near Miss ◽  
Long Working Hours ◽  
Near Misses ◽  
Related Stress ◽  
Job Related Stress

(1) Background: Near-miss incidents are the foundation of major injuries. They are warning signs that loss is imminent. Long working hours are a risk factor for near-misses along with sleep problems, job-related stress, and depressive symptoms. This study aimed to evaluate the indirect effects of long working hours via mediating variables on near-miss occurrences among Japanese healthcare professionals. (2) Methods: 1490 Japanese healthcare professionals’ reports from a web-based survey of workers in October 2018 were analyzed to evaluate total, direct, and indirect effects of long working hours on near-misses. We applied a generalized structural equation model with three mediating variables: sleep problems, job-related stress, and depressive symptoms. (3) Results: The total effect and direct effect of the categories of working hours longer than 41 h per week (h/w) for occurrence of near-misses were not significantly higher than that of 35–40 h/w. However, for indirect effects on occurrence of near-misses that first passed through job-related stress, there were higher reports for each category compared to 35–40 h/w, with odds ratios (OR) and 95% confidence intervals (95% CI) of OR = 1.12, 95% CI (1.07, 1.21) for 41–50 h/w; 1.25, (1.14, 1.41) for 51–60 h/w; and 1.31, (1.18, 1.51) for ≥ 61 h/w. (4) Conclusion: The results suggest that reducing working hours might improve job-related stress, which could reduce near-misses and prevent injuries.

scholarly journals Errors and Near-miss Errors Encountered by Nursing Students in Clinical Settings in Governmental Universities, Khartoum State (2018)

2020 ◽  
Author(s):  
Sahar Ahmed ◽  
Mohamed Toum ◽  
Samah Abdalla ◽  
Montahaa Mohammed
Keyword(s):  
Nursing Students ◽  
Sampling Method ◽  
Medication Administration ◽  
Cross Sectional Study ◽  
Near Miss ◽  
Clinical Settings ◽  
Error Management ◽  
Cross Sectional ◽  
Near Misses ◽  
Nursing Errors

Background: Identifying and analyzing the occurrence and sort of student clinical errors which will allow for early detection of problems and offer chance for system evaluation and improvement. This study intended to explain the types of errors along with near-miss errors encountered by nursing students in clinical settings. Methods: This descriptive cross-sectional study was conducted at five recognized governmental universities in Khartoum State and included 470 nursing students in their fourth year (2017–2018)who met the selection criteria of the study. A full-converge sampling method was used and data were first collected by the researcher using published self-administered survey and then analyzed. Results: Initially, the study included 519 nursing students but only 470 of them responded(at a rate of 90.5%).The responses showed that while one-third of them, that is, 162(34.5%) students, had never encountered an error, 99(21.1%), 79 (16.8%), 71 (15.1%), 46(9.8%), and 13(2.8%) of them encountered errors with respect to needle stick, medical administration, omission of treatment, and wrong treatment, respectively. Regarding the near-miss errors encountered by the respondents, almost half, that is, 202(43%)of them had never  encountered a near-miss errors, while 112(23.8%), 106(22.6%), 18(3.8%),17(3.6%), and 15(3.2%) of them encountered near-miss errors with respect to medication administration, omission of treatment, wrong  patient, providing wrong treatment and others   such as improper bedrail used, did not follow sterile precautions respectively. Conclusion: This study concluded that errors and near-miss errors exist and that awareness on clinical errors and near-misses need to be raised and strategies be developed for error management. Keywords: errors, near-miss errors, nursing students, clinical setting, nursing errors

scholarly journals Medication Safety Improves after Implementation of Positive Patient Identification

2010 ◽  
Vol 01 (03) ◽  
pp. 213-220 ◽  
Author(s):  
M. Heelon ◽  
B. Siano ◽  
L. Douglass ◽  
P. Liebro ◽  
B. Spath ◽  
...  
Keyword(s):  
Medication Safety ◽  
Near Miss ◽  
Positive Patient ◽  
Patient Identification ◽  
Post Intervention ◽  
Chi Square ◽  
Near Misses ◽  
Safety Reporting ◽  
Large Teaching Hospital ◽  
Before And After

Summary Objective: To report the incidence and severity of medication safety events before and after initiation of barcode scanning for positive patient identification (PPID) in a large teaching hospital. Methods: Retrospective analysis of data from an existing safety reporting system with anonymous and non-punitive self-reporting. Medication safety events were categorized as “near-miss” (unsafe conditions or caught before reaching the patient) or reaching the patient, with requisite additional monitoring or treatment. Baseline and post-PPID implementation data on events per 1,000,000 drug administrations were compared by chi-square with p<0.05 considered significant. Results: An average of 510,541 doses were dispensed each month in 2008. Total self-reported medication errors initially increased from 20 per million doses dispensed pre-barcoding (first quarter 2008) to 38 per million doses dispensed immediately post-intervention (last quarter 2008), but errors reaching the patient decreased from 3.26 per million to 0.8 per million despite the increase in “near-misses”. A number of process issues were identified and improved, including additional training and equipment, instituting ParX scanning when filling Pyxis machines, and lobbying for a manufacturing change in how bar codes were printed on bags of intravenous solutions to reduce scanning failures. Conclusion: Introduction of barcoding of medications and patient wristbands reduced serious medication dispensing errors reaching the patient, but temporarily increased the number of “near-miss” situations reported. Overall patient safety improved with the barcoding and positive patient identification initiative. These results have been sustained during the 18 months following full implementation.

scholarly journals Magnitude of maternal near misses and the role of delays in Ethiopia: a hospital based cross-sectional study

2019 ◽  
Vol 12 (1) ◽  
Author(s):  
Mulugeta Dile Worke ◽  
Habtamu Demelash Enyew ◽  
Maru Mekie Dagnew
Keyword(s):  
Antenatal Care ◽  
Health Care Access ◽  
Cross Sectional Study ◽  
Near Miss ◽  
Sectional Study ◽  
Cross Sectional ◽  
Near Misses ◽  
Care Access ◽  
Referral Hospitals

Abstract Objectives This study was aimed to assess the magnitude of maternal near misses and the role of delays including other risk factors. A Hospital based cross sectional study was conducted at three referral hospitals of Amhara region on 572 mothers who came to obtain obstetrics care services from February 01 to July 30, 2018. Results The magnitude of maternal near miss was 26.6% (95% CI 23, 30). With regards to delays, 83 (14.5%), 226 (39.5%), and 154 (26.9%) of women delayed in the decision to seek care, in reaching care, and in receiving care respectively. Women who had no antenatal care [AOR = 3.16; CI (1.96, 5.10)], who stayed in hospital 7 days or more [AOR = 2.20; CI (1.33, 3.63)] and those who had delay in reaching health facility [AOR = 1.99; CI (1.10, 3.61)] were more likely to be near miss. While, women whose husband was able to read and write [AOR = 0.29; CI (0.09, 0.96)] and those with monthly household income between 2001 and 3000 ETB [AOR = 0.35; CI (0.18, 0.70)] were 71% and 65% less likely to be near misses respectively. Promoting antenatal care and increasing maternal health care access could have significant impact in reducing maternal near misses.

scholarly journals Insights from Australians with respiratory disease living in the community with experience of self-managing through an emergency department ‘near miss’ for breathlessness: a strengths-based qualitative study

BMJ Open ◽  
2017 ◽  
Vol 7 (12) ◽  
pp. e017536 ◽  
Author(s):  
Tim Luckett ◽  
Jane Phillips ◽  
Miriam Johnson ◽  
Maja Garcia ◽  
Priyanka Bhattarai ◽  
...  
Keyword(s):  
Emergency Department ◽  
Self Efficacy ◽  
Near Miss ◽  
Self Management ◽  
Integrative Approach ◽  
Future Research ◽  
Management Approach ◽  
Chronic Obstructive ◽  
Pharmacological Management ◽  
Near Misses

ObjectivesBreathlessness ‘crises’ in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED ‘near misses’ where they considered going to the ED but successfully self-managed instead.Design and methodsA qualitative approach was used with a phenomenological orientation. Participants were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen’s Transactional Model of Stress and Coping informed interpretive themes.ResultsInterviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services.ConclusionsIn addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients’ generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge about when ED presentation is necessary. Complementary initiatives are needed to improve coordinated, person-centred care. Future research should seek ways to break the cyclical relationship between affective and sensory-perceptual dimensions of breathlessness.

scholarly journals The Near-Miss Effect in Slot Machines: A Review and Experimental Analysis Over Half a Century Later

2019 ◽  
Vol 36 (2) ◽  
pp. 611-632 ◽  
Author(s):  
Jeffrey M. Pisklak ◽  
Joshua J. H. Yong ◽  
Marcia L. Spetch
Keyword(s):  
Near Miss ◽  
Slot Machines ◽  
Operant Response ◽  
Extinction Procedure ◽  
Conditional Response ◽  
Near Misses ◽  
Resistance To Extinction ◽  
Effect Hypothesis ◽  
Human Participants ◽  
Simplified Procedure

Abstract In games of chance, a near miss is said to occur when feedback for a loss approximates a win. For instance, obtaining “cherry–cherry–lemon” on a slot machine could be considered a near miss. Sixty-six years ago, B.F. Skinner first proposed the idea that near-miss events might reinforce continued play in slot machines, and despite some inconsistencies in the experimental literature, belief in this “near-miss effect” has remained strong. In the present manuscript, we will review this literature and present experimental assessments of the near-miss effect on the frequency of the gambling response. Experiment 1 used a tightly controlled resistance-to-extinction procedure in pigeons to evaluate the putative reinforcing effect of near misses relative to a control “far-miss” reel pattern. Experiment 2 extended Experiment 1’s procedure to human participants. The results of both experiments failed to support the near-miss effect hypothesis. Experiment 3 used a further simplified procedure to assess the validity of the resistance-to-extinction paradigm when a probable conditional reinforcer was present on the reel stimuli. Although a clear conditional response was obtained from the reel, subsequent testing in extinction revealed no conditionally reinforcing function of this stimulus on operant response frequency.

The development of an outpatient chemotherapy medication safety program

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 16005-16005
Author(s):  
J. R. Hoverman ◽  
D. Richardson ◽  
K. Hansen ◽  
P. C. Dugger ◽  
K. M. Shuey
Keyword(s):  
Medication Safety ◽  
Rare Event ◽  
Near Miss ◽  
Occurrence Rate ◽  
Cancer Center ◽  
Institute Of Medicine ◽  
High Performing ◽  
Outpatient Chemotherapy ◽  
Reporting Tool ◽  
Reporting Mechanism

16005 Background: Through Institute of Medicine publications (To Err is Human) and through the public experience of a major cancer center, chemotherapy safety has been of concern. US Oncology, Inc. (USON) is the nations largest oncology management company, associated with over 900 medical, radiation, gynecologic and pediatric oncologists. In 2004 USON undertook a quality initiative with a principal objective a system-wide approach to medication safety. Methods: Medication safety was identified as a principal concern by a combined clinical/management committee. A questionnaire was prepared for each practice site to differentiate high performing practices in regards to variances from lower performing practices. 8 high performing practices and 8 lower performing practices were physically evaluated by team members. Neither the questionnaire nor onsite evaluation reliably differentiated quality processes. Three issues became apparent: no uniform reporting mechanism, multiple “double-check” interpretations and variable inclusion of medication safety into practice operations. The safety team undertook these first two issues. An online reporting tool was developed. “Double-check” was defined and processes mapped. Results: The team chose 1st hour of chemotherapy as the denominator for medication occurrence reporting. An online reporting tool was developed with now 1 year of experience. 83% of practice sites are reporting, accounting for 445,148 1st hours of chemotherapy. The occurrence rate is 0.66%. Of the total 0.13% is adverse drug reaction, 0.10% is near miss, 0.08% is miscalculation of dose, 0.05% is the wrong dose. Injury to a patient is a very rare event. Conclusions: The development of a culture of quality in an organization with affiliations of national scope is a formidable undertaking. These initial numbers have no comparative measure, as this is self-reporting using a novel denominator. However, there are within the network similar groups for comparison. The challenge continues to be developing a culture of reporting with systematic integration of those reports and quality processes into the fabric of the practice. [Table: see text]

Moving to secondary use of IT solutions: A provincial “near miss indicator” for chemotherapy.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 161-161
Author(s):  
Vishal Kukreti ◽  
Megan Teimoortagh ◽  
Annie Cheung ◽  
Sharon Gradin ◽  
John Gilks ◽  
...  
Keyword(s):  
Near Miss ◽  
Near Misses ◽  
Chemotherapy Drug ◽  
Secondary Use ◽  
Computerized Order Entry ◽  
Laboratory Values ◽  
Future System ◽  
Using Data ◽  
First Time ◽  
Order Entry Systems

161 Background: In Ontario, 93% of outpatient IV chemotherapy is prescribed through Systemic Treatment Computerized Order Entry Systems (ST CPOE). To support this, Cancer Care Ontario (CCO) has developed guidelines, evaluation tools, a Community of Practice (COP) and quality indicators. Using data collected in ST CPOE systems a “Near Miss Indicator” is being developed. Methods: Clinical consensus indicated that intercepted order rate, a proxy for a near miss indicator, would further the provincial safety agenda. This is defined as the percent of course 1, day 1 intravenous (IV) chemotherapy drug orders that were changed post-first time prescribing a new regimen (excludes clinical trials). An extraction standard for dose adjustments was developed encompassing clinical and laboratory values and body surface area (BSA). Three months of data was collected from 3 centres using the same ST CPOE system. Results: A total of 6822 orders were reviewed for possible near misses; 1,446 (21.2%) were course 1 orders. For course 1, day 1 IV chemotherapy drug orders, 209 (3.2%) were changed. Most orders were changed several hours to days post prescribing and hence were not felt to represent normal clinical workflows. Physicians modified 65 and pharmacy modified 169 orders. “Other” was chosen as the reason for change in 95 (45.5%) of orders and despite multidisciplinary team review, these records were not interpretable. A near miss rate of 2.2% resulted (32/1,446). Clinical and laboratory values and BSA were equally responsible. A fourth category of “dose rounding for ease” by pharmacy was identified and felt to possibly represent poor regimen builds and pharmacy workload. Conclusions: A near miss indicator is under development via a process of identifying a need, exploration of data and socialization of the results through a COP. Initial results show a low near miss indicator rate of 2.2% which is felt to be clinically actionable. Future system modifications may facilitate capture of this indicator. The feasibility of extending the indicator to multiple vendor ST CPOEs is under study.

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