|
NPSF Bibliography
NPSF CURRENT AWARENESS PATIENT SAFETY LITERATURE ALERT
AUGUST #1, 2004
The NPSF Information Resource Center, in an effort to monitor the landscape of patient safety, routinely identifies articles that may be of interest to the patient safety community. This twice-monthly publication is not an exhaustive list of citations, but does pinpoint items of interest from a wide array of publications. Copies of the articles may be obtained through your local medical or public library and the web.
When available, hyperlinks are provided. At means the full-text is available on-line. Through means the item is available for purchase on-line. Also, check Journal Sources for additional information on a given article.
Our thanks go Adam Scheffler and Tim Vanderveen for their contributions to this edition of Current Awareness.
1. Hospitalized poisonings after renal transplantation in the United States.
Abbott KC, Viola RA, Agodoa LY.
BMC Nephrol. 2004;1(2):1-8.
Available at: http://www.biomedcentral.com/1472-6963/1/2.
This study found the incidence of hospitalized poisoning was 2.3 patients per 1000 person years and that these were independently associated with increased mortality and generally due to the use of prescribed medications. Although the possibilities of patient error vs. provider error could not be distinguished, consultation with pharmacists is recommended to reduce both.
Refs: 28 / Code: ADM; MED; REL
2. ACGME's approach to limit resident duty hours 12 months after implementation: a summary of achievements.
Chicago, Ill: Accreditation Council for Graduate Medical Education; 2004.
Available at: http://www.acgme.org/DutyHours/dutyhoursummary2003-04.pdf.
To meet the new ACGME standards, this study found that changes in clinical training included use of schedule changes, night float and other rotation changes, replacing resident services with care by nurse practitioners, physician assistants or hospitalists, re-engineering patient care and educational systems, and increasing clinical responsibilities of faculty physicians. Highlights of the achievements and future refinements are discussed.
Code: ADM
3. Qualitative study of attitudes toward error in patients facing brain tumour surgery.
Bernstein M, Potvin D, Martin DK.
Can J Neurol Sci. 2004;31(2):208-212.
This study examined patients' perceptions and attitudes regarding medical error found that trust in the surgeon was of paramount importance, views toward error varied from fear to no concern, and discussion of error was felt to be beneficial in both decreasing potential future errors and dispelling anxiety about the upcoming surgery.
Refs: 34 / Code: REL
4. Preventing errors in clinical practice: a call for self-awareness.
Borrell-Carrio, F, Esptein RM.
Ann Fam Med. 2004;2(4):310-316.
Available at: http://www.annfammed.org/cgi/content/full/2/4/310.
Focusing on the individual rather than the system, the rational-emotive model presented in this paper emphasizes difficulty in reframing a first hypothesis and premature closure of the clinical act to avoid confronting inconsistencies, low-level decision rules, and emotions - both of which are factors in medical error. Examples are presented in case studies and a teaching strategy to develop insight and self-awareness is recommended.
Refs: 29 / Code: DEC
5. Righting wrong site surgery.
Carayon P, Schultz K, Hundt AS.
Jt Comm J Qual Safety. 2004;30(7):405-410.
In this human factors analysis, the individual, tasks, tools and technologies, physical environment, and organizational conditions are applied to a case study. Specific solutions, for example the timing of the consent form, need to consider the specific characteristics of the local work system and organizational culture. Five recommendations are included.
Refs: 11 / Code: ERG; SUR
6. New method of classifying infections in critically ill patients.
Cohen J, Cristofara P, Carlet J, Opal S.
Crit Care Med. 2004;32(7):1510-1526.
Available through: http://www.ccmjournal.com/pt/re/ccm/toc.00003246-200407000-00000.htm.
From this systematic literature review a Grading System for Site and Severity of Infection was developed which considers both the nature of the organism and the site of infection.
Refs: 33 / Code: INF
7. Implementing a hospitalwide patient safety program for cultural change.
Cohen MM, Kimmel NL, Benage MK, Hoang CC, Burroughs TE, Roth CA.
Jt Comm J Qual Safety. 2004;30(8):424-431.
The Missouri Baptist Medical Center embarked on a comprehensive patient safety program to move from a punitive to a just culture. Discussion covers structures, processes, and initiatives that were introduced over two years to change attitudes at all levels, communicate with staff and community, and to provide feedback on leadership's responses. Reporting increased significantly and continues in the year following implementation of the program.
Refs: 26 / Code: ADM; ERG
8. Physiatry: medical errors, patient safety, patient injury, and quality of care.
DeLisa JA.
Am J Phys Med Rehab. 2004;83(8):575-583.
This paper reviews the definition of medical error, the barriers to reporting errors, and the physicians' responsibility and activity continuum - from slips to negligence. Active and latent failures, factors influencing clinical practice and contributing to adverse events, and curriculum components for teaching patient safety are discussed.
Refs: 38 / Code: CORE; EDU; GEN
9. Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative.
Fernald DH, Pace WD, Harris DM, West DR, Main DS, Westfall JM.
Ann Fam Med. 2004;2(4):327-332.
Available at: http://www.annfammed.org/cgi/content/full/2/4/327.
This web-based reporting system allowed for both anonymous and confidential reports, the latter permitting follow-up interviews and resulted in 708 reports over two years. Of the codable reports, the most frequently reported errors involved communication problems (70%), diagnostic tests (47%) and medication problems (35%). The authors conclude a safe and secure reporting system relying on voluntary reporting can be successfully implemented. Further studies are needed to clarify appropriate levels of reporting detail and optimal levels of coding detail.
Refs: 32 / Code: REPR
10. Pharmacist surveillance of adverse drug events.
Forster AJ, Halil RB, Tierney MG.
Am J Health-Syst Pharm. 2004;61(14):1466-1472.
This study found 4.4 ADEs per 100 patient days, half of which were preventable; all preventable and potential ADEs occurred during the ordering and administering stages of medication delivery. The majority of the staff felt this type of surveillance was non-threatening, believed it did not impeded normal activities, and wanted to see the surveillance continue.
Refs: 23 / Code: MED
11. Inappropriate use of urinary catheters in elderly patients at a Midwestern community teaching hospital.
Gokula RR, Hickner JA, Smith MA.
Am J Infect Contr. 2004;32(4):196-199.
This study found that less than half of urinary catheterizations were indicated and only 13% had an explicit indication recorded in the chart. No order was written in one-third of the cases. Hospital guidelines and an indication sheet may reduce the incidence of inappropriate catheterization and, consequently, infections.
Refs: 17 / Code: GER; INF
12. Proactive management breaks the fall cycle: at-risk patients benefit from a care approach that embraces highly sensitive technology and ever-vigilant clinicians.
Jackson L, Gleason J.
Nurs Manag. 2004;35(6):37-38.
At St. Clare Hospital, the fall prevention approach includes installation of electronic sensing devices, development of a staff performance improvement initiative, continual education and training, ongoing assessment, and evaluation. Results include a 99% decrease in restraint usage and a call for applying the bed safety monitoring system to chairs and wheelchairs.
Refs: 1 / Code: GER; HMI
13. Patient reports of preventable problems and harms in primary health care.
Kuzel AJ, Woolf SH, Gilchrist VJ, et al.
Ann Fam Med. 2004;2(4):333-340.
Available at: http://www.annfammed.org/cgi/content/full/2/4/333.
This study to develop patient-focused typologies of medical errors and harms found that breakdowns in access to and relationships with clinicians may be more prominent medical errors than are the technical errors in diagnosis and treatment. Tables include a taxonomy of unique events associated with preventable harm and a list of preventable harms in the categories of psychological, physical, and economic.
Refs: 36 / Code: REL
14. Mediation skills model to manage disclosure of errors and adverse events to patients: a quicker, less alienating route to closure than malpractice litigation.
Liebman CB, Hyman CS.
Health Affairs. 2004;23(4):22-32.
Available through: http://content.healthaffairs.org/cgi/content/abstract/23/4/22.
This model was developed through the Pew Demonstration Medication and ADR Project and includes training the communicators, planning and conducting the disclosure discussions and, after disclosure, support for health care providers and claim resolution. Differences between this model and the ones developed by Rush University Medical Center are discussed.
Refs: 28 / Code: DISC
15. Effect of smart infusion pumps on medication errors related to infusion device programming.
Malashock CM, Shull SS, Gould DA.
Hosp Pharm. 2004;39(5):433-459.
This observational, prospective study examined how often smart infusion devices alerted users, types of alerts, medications involved, and trends in the use of device. Discussion focuses on reprogramming alerts with the resulting prevention of potentially fatal errors, override alerts, and user satisfaction.
Refs: 7 / Code: HMI; MED
16. $181,000 adverse drug reaction.
McDonnell PJ.
Hosp Pharm. 2004;39(7):648-652.
Discussing the case of a preventable medication error due to lack of communication between several doctors and complete medical history. Discussion includes terminology and methods to prevent future ADRs.
Refs: 22 / Code: MED; REL
17. Hospital quality: ingredients for success-overview and lessons learned.
Meyer JA, Silow-Carroll S, Kutyla T, Stepnick LS, Rybowski LS.
New York, NY: Commonwealth Fund; 2004.
Available at: http://www.cmwf.org/programs/quality/meyer_hospitalquality_761.asp.
This study found that the key elements in producing high-quality hospital care are: supportive culture and policies, right people, effective in-house processes, and the right tools to do the job, plus external factors such as quality initiatives and standards and market competition. Case studies from Beth Israel Deaconess Medical Center, El Camino Hospital, Mission Hospitals, and Jefferson Regional Medical Center are included.
Code: ADM; GEN; HMI
18. Patient misidentification in a pediatric emergency department: patient safety and legal perspectives.
O'Neill KA, Shinn D, Starr KT, Kelley J.
Pediatr Emerg Care. 2004;20(7):487-492.
This article discusses a case study involving patient misidentification and reviews the legal risks and the safety programs implemented at AIDCH to improve patient outcomes. A seven point summary to ensure positive patient identification is included.
Refs: 11 / Code: ADM; PED
19. Linking patient and family-centered care and patient safety: the next leap.
Ponte PR, Connor M, DeMarco R, Price J.
Nurs Econ. 2004;22(4):221-213,215.
At Dana-Farber Cancer Institute the patient's perspective is desired at every level of decision making through advisory councils. Discussion also focuses on a new project of patient safety rounds to include patients and families.
Refs: 8 / Code: ADM; REL
20. New JCAHO medication management standards for 2004.
Rich DS.
Am J Health-Syst Pharm. 2004;61(13):1349-1358.
Thorough discussion of the JCAHO standards related to medication and specifically the changes in the standards from past requirements.
Refs: 6 / Code: MED
21. Surgical fires: learn not to burn.
Smith C.
AORN J. 2004;80(1):24-27,2931,33-34,36.
Noting that virtually all fires ignite on or in the patient, discussion covers understanding and recognizing fire hazards, materials needed to build a fire (fuel, oxygen, heat and complacency), education, and preventing and managing fires. A summary of ECRI's Clinician's Guide to Surgical Fires is included. A related article in the same journal discusses the OR fire drill is: Salmon L. Fire in the OR: prevention and preparedness. Pg 42,44-48,51-53.
Refs: 8 / Code: ADM; SUR
22. Medical errors: lessons from aviation.
Smith MS.
Med Econ. 2004;81(12):60-61,65.
Topics and examples include fatigue, high workload, multi-tasking, information overload, assumptions, and similar names. The author concludes with a call for a medication safety reporting system similar to that of the ASRS.
Code: GEN
23. Hospital capacity, productivity, and patient safety: it all flows together.
Zimmerman RS.
Front Health Serv Manag. 2004;20(4):33-38.
Introducing three articles on patient flow, a common theme of apparent limitation of capacity is actually caused by inefficiencies in clinical hospital operations. The need for integrated change and alignment and the link between patient flow and patient safety is discussed. Related articles in the same journal are: Haraden C, Resar R. Patient flow in hospitals: understanding and controlling it better. Pg 3-15; Henderson, D, Dempsey C, Appleby D. Case study of successful patient flow methods: St. John's Hospital. Pg 25-30; Horton SS. Increasing capacity while improving the bottom line. Pg 17-23.
Refs: 4 / Code: ADM
Copyright 2004 National Patient Safety Foundation®
compiled by Holly Burt, MLIS, for the National Patient Safety Foundation®
|
