Hypoglycemia from a look-alike, sound-alike medication error

2015 ◽  
Vol 5 (4) ◽  
pp. 174-179
Author(s):  
Robin M. Milton ◽  
Nicole B. Washington ◽  
Nancy Brahm
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Health Care Professionals ◽  
Psychiatric Patients ◽  
Well Being ◽  
The United States ◽  
Community Treatment ◽  
Drug Event ◽  
Hypoglycemic Episode ◽  
Corrective Actions

Abstract Objective To describe the effects of a look-alike, sound-alike medication error on the glycemic control and psychiatric well-being of a 23-year-old man. Case Summary A 23-year-old man presented to the university-based Integrated Multidisciplinary Program of Assertive Community Treatment (IMPACT) team with a diagnosis of schizoaffective disorder, most recent episode manic, and hypertension. The patient was prescribed chlorpromazine 100 mg daily to treat symptoms of psychosis and anxiety. The anxiety, however, persisted and escalated over the following 2 weeks. Upon physical examination of the patient's medications, it was discovered that the patient was inadvertently given chlorpropamide in place of the chlorpromazine. Evaluations, clinical presentation, the medication list, and criteria for an adverse drug event indicated a probable relationship (7 of 12) between the use of chlorpropamide and a hypoglycemic episode. The medication error was noted and corrective actions were taken. Within 1 week of the corrective actions, the patient's anxiety improved. Discussion When working with psychiatric patients, it is important to physically review all medications when expected responses are not achieved or when new psychiatric or physiological symptoms present. Approximately one-fourth of medication errors in the United States are drug name confusion errors. These errors must be universally addressed by all parties involved in the medication process. Effective safeguards are available and must be implemented by manufacturers, physicians, pharmacists, nurses, and all health care professionals to prevent look-alike, sound-alike medication errors.

Accuracy of Antiretroviral Prescribing in a Community Teaching Hospital: A Medication Use Evaluation

2019 ◽  
pp. 089719001985784
Author(s):  
Jacob Lines ◽  
Paul Lewis
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Medication Error ◽  
Medication Errors ◽  
Retrospective Chart Review ◽  
The United States ◽  
Error Rates ◽  
Transitions Of Care ◽  
Hiv Diagnosis ◽  
Increased Risk

Background: Medication errors account for nearly 250 000 deaths in the United States annually, with approximately 60% of errors occurring during transitions of care. Previous studies demonstrated that almost 80% of participants with human immunodeficiency virus (HIV) have experienced a medication error related to their antiretroviral therapy (ART). Objective: This retrospective chart review examines propensity and type of ART-related errors and further seeks to identify risk factors associated with higher error rates. Methods: Participants were identified as hospitalized adults ≥18 years old with preexisting HIV diagnosis receiving home ART from July 2015 to June 2017. Medication error categories included delays in therapy, dosing errors, scheduling conflicts, and miscellaneous errors. Logistic regression was used to examine risk factors for medication errors. Results: Mean age was 49 years, 76.5% were men, and 72.1% used hospital-supplied medication. For the primary outcome, 60.3% (41/68) of participants had at least 1 error, with 31.3% attributed to delays in therapy. Logistic regression demonstrated multiple tablet regimens (odds ratio [OR]: 3.40, 95% confidence interval [CI]: 1.22-9.48, P = .019) and serum creatinine (SCr) ≥1.5 mg/dL (OR: 8.87, 95% CI: 1.07-73.45, P = .043) were predictive for risk of medication errors. Regimens with significant drug–drug interactions (eg, cobicistat-containing regimens) were not significantly associated with increased risk of medication errors. Conclusions and Relevance: ART-related medication error rates remain prevalent and exceeded 60%. Independent risk factors for medication errors include use of multiple tablet regimens and SCr ≥1.5 mg/dL.

A survey of national trends in psychiatric patients found incompetent to stand trial: reasons for the reinstitutionalization of people with serious mental illness in the United States

CNS Spectrums ◽  
2020 ◽  
Vol 25 (2) ◽  
pp. 245-251
Author(s):  
Katherine Warburton ◽  
Barbara E. McDermott ◽  
Anthony Gale ◽  
Stephen M. Stahl
Keyword(s):  
Psychiatric Patients ◽  
National Level ◽  
District Of Columbia ◽  
The United States ◽  
Community Treatment ◽  
Specific Information ◽  
General Mental Health ◽  
Forensic Patients ◽  
State Hospitals ◽  
Incompetent To Stand Trial

Objective.Recent information indicates that the number of forensic patients in state hospitals has been increasing, largely driven by an increase in patients referred to state hospitals as incompetent to stand trial (IST). This survey was intended to broaden the understanding of IST population trends on a national level.Methods.The authors developed a 30-question survey to gather specific information on IST commitments in each state and the District of Columbia. The survey was administered to all 50 states and the District of Columbia via email. Specific individuals identified as primary administrators responsible for the care and evaluation of IST admissions in each state were contacted.Results.A total of 50 out of the 51 jurisdictions contacted completed the survey. Fully 82% of states indicated that referrals for competency evaluation were increasing. Additionally, 78% of respondents thought referrals for competency restoration were increasing. When asked to rank factors that led to an increase, the highest ranked response was inadequate general mental health services in the community. Inadequate crisis services were the second ranked reason. Inadequate number of inpatient psychiatric beds in the community was the third highest, with inadequate assertive community treatment services ranking fourth.Conclusions.Understanding the national trend and causes behind the recent surge in referrals for IST admissions will benefit states searching for ways to remedy this crisis. Our survey indicates most states are facing this issue, and that it is largely related to insufficient services in the community.

scholarly journals The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems

Medicines ◽  
2021 ◽  
Vol 8 (9) ◽  
pp. 46
Author(s):  
Abbas Al Mutair ◽  
Saad Alhumaid ◽  
Abbas Shamsan ◽  
Abdul Rehman Zia Zaidi ◽  
Mohammed Al Mohaini ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
The United States ◽  
Population Based ◽  
Error Reporting ◽  
Effective Strategies ◽  
Medication Error Reporting ◽  
Background Population ◽  
Safety Improvement ◽  
Reporting Systems

Background: Population-based studies from several countries have constantly shown excessively high rates of medication errors and avoidable deaths. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Improvement efforts and system changes of medication error reporting systems should be targeted towards reductions in the likelihood of injury to future patients. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems. Methods: Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles were found and 60 papers were ultimately included in the review. Data were mined by two reviewers and verified by two other reviewers. The search yielded 684 articles, which were then reduced to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers. Results: Studies were principally from the United States of America and the United Kingdom. Limited studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt. Detection, measurement, and analysis of medication errors require an active rather than a passive approach. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). The National Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification system to describe and analyze the details around individual medication error events. Conclusion: A successful medication error reporting program should be safe for the reporter, result in constructive and useful recommendations and effective changes while being inclusive of everyone and supported with required resources. Health organizations need to adopt an effectual reporting environment for the medication use process in order to advance into a sounder practice.

scholarly journals Ultrasound Education in the United States

2013 ◽  
Vol 7 (3) ◽  
pp. 329-331
Author(s):  
Ivica Zalud ◽  
Pai-Jong Stacy Tsai ◽  
Shelby Wong
Keyword(s):  
United States ◽  
Health Care Professionals ◽  
Medical Training ◽  
New Technology ◽  
Fetal Surgery ◽  
Well Being ◽  
The United States ◽  
Diagnostic Modality ◽  
Ultrasound Education ◽  
Uterine Anomalies

ABSTRACT More than any other diagnostic modality, ultrasound has made dramatic imprints on diagnosis of pregnancy, fetal well-being, detection of anomalies and aneuploidy, fetal surgery and intrauterine interventions, and early detection of pelvic masses and uterine anomalies. Continuous ultrasound education is needed to provide health care professionals the proper environment to make sound clinical judgments, accurate diagnosis and management plans. As medical technology becomes more sophisticated, new medical training will evolve. The medical educators’ responsibility is to ensure that new technology will be used properly to improve and maintain the health of patients. This is a review article on obstetrics and gynecology ultrasound education in the United Sates of America with specific focus on Hawaii experience. How to cite this article Tsai PJS, Wong S, Zalud I. Ultrasound Education in the United States. Donald School J Ultrasound Obstet Gynecol 2013;7(3):329-331.

Hispanics, Mental Health, and Discriminating Policies: Brief Report

2019 ◽  
Vol 17 (4) ◽  
pp. 178-180
Author(s):  
Francisco Brenes
Keyword(s):  
Mental Health ◽  
Health Care ◽  
Health Care Professionals ◽  
Health Care Disparities ◽  
Minority Group ◽  
Well Being ◽  
The United States ◽  
Physical Disorders ◽  
Positive Correlations ◽  
Immigrant Policies

Hispanics, the largest minority group in the United States, are a heterogeneous group that contains a large portion of immigrants from Latin America. Recently, anti-immigrant policies and anti-Hispanic discriminatory practices have heightened at state and national levels. These policies and practices serve to endanger the mental health of Hispanics and play a major role in health care disparities. Positive correlations have been found between chronic discrimination and depression as well as other comorbid conditions, such as anxiety and substance use, and physical disorders. This report provides an overview of the changes in law/policy in recent history that negatively affect the well-being of Hispanics. Recommendations for health care professionals, educators, and researchers are presented.

Příčiny a intervence medikačního pochybení ve zdravotnických zařízeních

2021 ◽  
Vol 70 (1) ◽  
pp. 43-50
Author(s):  
Neugebauer Jan ◽  
Tóthová Valérie ◽  
Chloubová Ivana ◽  
Hajduchová Hana ◽  
Brabcová Iva ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Human Factor ◽  
Adverse Event Reporting System ◽  
The United States ◽  
Adverse Event Reporting ◽  
Technical Factor ◽  
Healthcare Facilities ◽  
Set Up ◽  
Fear And Anxiety

A medication error is one of the most common causes of patients’ complications or death in healthcare facilities. In the United States, 7,000 out of 9,000 patients die because of medication errors each year. Known factors are generally divided into four groups – human factor, intervention, technical factor, and system. Our study includes 17 studies from the OVID, Web of Science, Scopus, and EBSCO databases, in the range of 2015–2020. After a selection of professional publications, 2 categories were created – factors leading to medication errors and interventions to reduce medication error and testing their effectiveness. It has been found that human factor always plays a role, often supported by a poorly set-up system. The most mistakes are made in documentation, administration technique or accidental interchange of patients. The most frequently mentioned factors include nurses’ overload, high number of critically ill patients, interruptions in the preparation or in the administration of medications, absence of the adverse event reporting system, non-compliance with guidelines, fear, and anxiety. Another evidence of medication error is in the application of intravenous drugs, where an interchange of drugs or patients due to interruption occurs as well. Sufficient education of nurses and an adequate system of preparation and administration of drugs, for example using bar codes, are considered as an appropriate intervention.

INTERNATIONAL PERSPECTIVES ON WELL-BEING AND BURNOUT WITHIN HEALTH SYSTEMS

2021 ◽  
Vol 9 (1) ◽  
pp. 11-25
Author(s):  
James Appleyard
Keyword(s):  
Health Care ◽  
Work Environment ◽  
Health Systems ◽  
Professional Education ◽  
Health Care Professionals ◽  
Health Care Systems ◽  
Well Being ◽  
The United States ◽  
Clinical Event ◽  
Individual Doctor

Objectives: To reflect on the present international culture of professional burnout in health care systems and the need for a radical new approach with an increased understanding of a person- and people-centered attitudes in the promotion of training in wellbeing and the prevention and management of burnout among physicians and health care professionals Methods: A literature search worldwide was undertaken for significant research papers on professional education related to burnout with particular reference to both medical staff resilience and health care system factors. Findings: Burnout among doctors is a global phenomenon. The incidence of burnout reported in a selection of studies among pediatric residents and staff are 25% in Argentina, 37% in the United Kingdom, and 70% in Saudi Arabia. In a national survey in the United States where the overall rate was 59% burned out residents reported significantly increased stress, poorer mental health, and decreased empathy, mindfulness, resilience, self-compassion, and confidence in providing compassionate care Three levels of change that should be the focus of training in prevention, health promotion, and stress reduction awareness have been recommended to reduce the risk of burnout: (1) modifying the organizational structure and work processes; (2) improving the fit between the organization and the individual doctor through professional development programs so that better adaption to the work environment occurs; and (3) individual-level actions to reduce stress and poor health symptoms through effective coping and promoting healthy behavior. Discussion: The history of burnout shows important links with increased work complexity. Narrow training interventions such as debriefing after an adverse clinical event have not been found effective. A more comprehensive personcentered approach with a variety of measurable interventions has resulted in a reduction of 50% in the pediatric faculty in one study. A person- and people-centered cybernetic approach is needed with six standards are to establish and sustain a healthy work environment (1) authentic leadership (2) meaningful recognition, (3) skilled communication, (4) true collaboration, (5) effective decision making, and (6) appropriate staffing. Conclusion: With such high levels of burnout, health systems worldwide can be viewed as failing their populations on a grand scale. Only an organizational paradigm change to a person- and people cybernetic centered system that incorporates complexity is adaptive and integrative will a health system be effective in preventing and ameliorating the effects of burnout and reduce the increasingly unaffordable misuse of human resources.

Self-care Strategies to Combat Burnout Among Pediatric Critical Care Nurses and Physicians

2020 ◽  
Vol 40 (2) ◽  
pp. 44-53 ◽  
Author(s):  
Holly Wei ◽  
Hadley Kifner ◽  
Melanie E. Dawes ◽  
Trent L. Wei ◽  
Jenny M. Boyd
Keyword(s):  
Health Care ◽  
Critical Care ◽  
Health Care Professionals ◽  
Self Care ◽  
Well Being ◽  
The United States ◽  
Professional Burnout ◽  
Pediatric Critical Care ◽  
Qualitative Descriptive ◽  
Nurses And Physicians

Background Professional burnout is a widespread phenomenon in health care. The health of patients and organizations begins with the well-being of health care professionals. Identifying and understanding self-care strategies that professionals perceive to be helpful is crucial to combat burnout. Objective To determine perceptions of self-care strategies to combat professional burnout among nurses and physicians in pediatric critical care settings. Methods This was a qualitative descriptive study with a phenomenological overtone. The study was conducted in a 20-bed pediatric intensive care unit and an 8-bed intermediate care unit of a children’s hospital in the United States. Information flyers and emails were used to introduce the study. A combination of convenience and purposive sampling methods was used to recruit participants who were full-time nurses and physicians in the 2 units. Information saturation was used to regulate sample sizes, resulting in 20 participants. Data were collected through a onetime face-to-face interview with each participant. A qualitative descriptive approach was used to analyze the data. The first author was the primary coder and discussed the codes with the coauthors throughout the coding process. Results Six major self-care strategies were identified: finding meaning in work, connecting with an energy source, nurturing interpersonal connections, developing an attitude of positivity, performing emotional hygiene, and recognizing one’s uniqueness and contributions at work. Conclusions Developing effective self-care strategies helps promote health care professionals’ physical and psychological well-being and reduce burnout. It is vital for health care professionals to care for themselves so that they can best care for others.

scholarly journals Cyberincivility in the Massive Open Online Course Learning Environment: Data-Mining Study (Preprint)

2018 ◽  
Author(s):  
Jennie C De Gagne ◽  
Kim Manturuk ◽  
Hyeyoung K Park ◽  
Jamie L Conklin ◽  
Noelle Wyman Roth ◽  
...  
Keyword(s):  
Health Care ◽  
Learning Environment ◽  
Health Care Professionals ◽  
A Priori ◽  
Well Being ◽  
The United States ◽  
General View ◽  
Discussion Forums ◽  
Massive Open Online ◽  
Health Related

BACKGROUND Cyberincivility is a pervasive issue that demands upfront thinking and can negatively impact one’s personal, professional, social, and educational well-being. Although massive open online courses (MOOCs) environments could be vulnerable to undesirable acts of incivility among students, no study has explored the phenomena of cyberincivility in this learning environment, particularly in a health-related course in which mostly current or eventual health professions students enroll. OBJECTIVE This study aimed to analyze the characteristics of text entries posted by students enrolled in a medicine and health care MOOC. The objectives were to (1) examine the prevalence of posts deemed disrespectful, insensitive or disruptive, and inconducive to learning; (2) describe the patterns and types of uncivil posts; and (3) highlight aspects that could be useful for MOOC designers and educators to build a culture of cybercivility in the MOOC environment. METHODS We obtained data from postings in the discussion forums from the MOOC Medical Neuroscience created by a large private university in the southeast region of the United States. After cleaning the dataset, 8705 posts were analyzed, which contained (1) 667 questions that received no responses; (2) 756 questions that received at least one answer; (3) 6921 responses that applied to 756 posts; and (4) 361 responses where the initiating post was unknown. An iterative process of coding, discussion, and revision was conducted to develop a series of a priori codes. Data management and analysis were performed with NVivo 12. RESULTS Overall, 19 a priori codes were retained from 25 initially developed, and 3 themes emerged from the data—Annoyance, Disruption, and Aggression. Of 8705 posts included in the analysis, 7333 (84.24%) were considered as the absence of uncivil posts and 1043 (11.98%) as the presence of uncivil posts, while 329 (3.78%) were uncodable. Of 1043 uncivil posts analyzed, 466 were coded to >1 a priori codes, which resulted in 1509 instances. Of those 1509 instances, 826 (54.74%) fell into “annoyance”, 648 (42.94%) into “disruption”, and 35 (2.32%) into “aggression”. Of 466 posts that related to >1 a priori codes, 380 were attributed to 2 or 3 themes. Of those 380 posts, 352 (92.6%) overlapped both “annoyance” and “disruption,” 13 (3.4%) overlapped both “disruption” and “aggression,” and 9 (2.4%) overlapped “annoyance” and “aggression,” while 6 (1.6%) intersected all 3 themes. CONCLUSIONS This study reports on the phenomena of cyberincivility in health-related MOOCs toward the education of future health care professionals. Despite the general view that discussion forums are a staple of the MOOC delivery system, students cite discussion forums as a source of frustration for their potential to contain uncivil posts. Therefore, MOOC developers and instructors should consider ways to maintain a civil discourse within discussion forums.

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