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NPSF Bibliography
Patient Safety Literature Current Awareness Alert
May #2, 2003
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.
This list is submitted twice a month to patientsafety-L as a service to help subscribers stay aware of relevant literature. The NPSF invites authors to submit materials to us for possible inclusion in future lists of this nature. To view previous patient safety current awareness listings, please visit the list archives at http://patientsafety-l@listserv.npsf.org/archives/index.html
Our thanks go to Ilene Corina, Jennifer Dingman, Benjamin Grasso, Theresa Pape, Lawrence Way and Donna Young for their contributions to this edition of Current Awareness.
1. Banja JD. Disclosing medical error: how much to tell. J Healthc Risk Manag. 2003;23(1):11-14.
The article presents three ethically based responses recommending a generous policy on disclosure. The fiduciary relationship is discussed and the author concludes anything less than a policy of extreme honesty in disclosing error amounts to contractual outrage.
Refs: 13 / Code: DISC; REL
2. Carthey J, de Leval MR, Wright DJ, Farewell VT, Reason JT, UK paediatric cardiac centers. Behavioural markers of surgical excellence. Safety Sci. 2003;41(5):409-425.
This study identified 21 behavioral markers at individual, team and organizational levels. The five surgeons with the highest procedural excellence scores were highly adaptive, worked within responsive teams, in organizations that always prioritized clinical goals over non-clinical demands on the surgeon and had policies reducing potential sources of distraction.
Refs: 33 / Code: ADM; SUR
3. Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med. 2003;114(5):404-407.
To reduce the catheter-related infections and number of unnecessary catheters, the VA Puget Sound Health Care System established automatic physician reminders. This study found an increased rate of documentation for catheter placement (from 29 to 92 percent) and the mean duration of catheterization was reduced by one-third.
Refs: 20 / Code: SUR
4. ECRI. Nonpunitive error-reporting programs: overcoming the problem of fear. Risk Manag Reporter. 2003;22(3):1,3-9.
Description of programs implemented around the country. The process includes identifying what to report (some focusing on near misses and others on errors reaching the patient), staff involvement, education, positive reinforcement and accountability, and applying simple fixes from the reports. A sidebar discusses on the pressure to punish by governmental agencies and the public.
Code: ADM
5. Foster RA, Antonelli RJ. Computerized physician-order entry: are we there yet?. Otolaryngol Clin N Am. 2002;35(6):1237-1243.
This article reviews the issues surrounding medication errors and examines the factors involving CPOEs including the benefits and barriers to implementation and reasons why a CPOE program may fail.
Refs: 30 / Code: MED
6. Gibson R, Singh JP. Wall of silence. Washington, DC: LifeLine Press; 2003. # 0-89526-112-X.
This book, takes a comprehensive look at errors and the medical system from the patient's perspective. The authors call for diligence on the part of patients, open and honest disclosure by healthcare providers, a central reporting agency, and a culture for learning from mistakes rather than hiding them. The book closes with a chapter on steps patients may take to protect themselves from medical error.
Refs: 53 / Code: GEN; REL
7. Grasso BC, Genest R, Jordan CW, Bates DW. Use of chart and record review to detect medication errors in a state psychiatric hospital. Psychiatr Serv. 2003;54(5):677-687.
This study found that medication error rates in psychiatric hospitals was comparable to, although distribution of errors differed from, those in general care units resulting in an estimated annual rate of 44,000 errors. Only 0.4 percent of medication errors were self-reported. Using a review team to detection of and establishing clinical measures for decreasing medication errors is highly recommended. Grasso and Bates in "Medication errors in psychiatry: are patients being harmed", pg 599, recommend psychiatrists learn about issues in medication errors, hospitals staff be educated in factors leading to errors and performance improvement activities be guided by this knowledge.
Refs: 25 / Code: ADM; MED
8. Harrington C, O'Meara J, Kitchener M, Simon LP, Schnelle JF. Designing a report card for nursing facilities: what information is needed and why. Gerontologist. 2003;43 (Sp Iss 2):47-57.
Six key areas of information were identified based on a literature review: facility and resident characteristics, staffing, clinical quality and financial indicators, and deficiencies. Each of these area are described and how this information may be used is discussed.
Refs: 85 / Code: ADM
9. Heatlie JM. Reducing insulin medication errors: evaluation of a quality improvement initiative. J Nurs Staff Dev. 2003;19(2):92-98.
After finding long delays in the dosing of insulin after blood glucose, a new process was set in place resulting in significant increases in the percentages of cases where insulin administration took place within one hour. The findings of this study support he importance of evaluation by staff development educators in the improvement of a process improvement plan.
Refs: 12 / Code: MED
10. Higginbohtam E. Does error + injury = negligence?: not necessarily, explains this author. RN. 2003;66(5):67-68.
Using an example of a medication error during an emergency, the author examines the legal elements defining negligence.
Refs: 3 / Code: MED
11. Lesar R, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Safety. 2003;29(5):211-226.
In using and applying the self-assessment program, the VHA New England Medication Errors Prevention Initiative (MEPI) increased their aggregate score over 15% in two years. Discussion includes the learning shared and a sidebar case study focuses on the steps taken by Central Maine Healthcare and obstacles and results of implementing action plans.
Refs: 27 / Code: ADM; MED
12. Lindberg DL, Maletta MM. Examination of memory conjunction errors in multiple client audit environments. Auditing. 2003;22(1):127-141.
This study examined the specific factors affecting the extent and nature of conjunction memory errors (where one event incorrectly attributed to a different event). Twice as many errors were committed for similar events than new ones and three times as many for very dissimilar, high-risk events. The authors also found that these errors may play a significant role in elements of the planning process.
Refs: 45 / Code: ERG
13. Morrissey J. Always vigilant. Modern Healthc. 2003;33(21):28,30,35.
Over 1,000 timely computerized alerts saved a projected 1500 patient days and at least $2 million in avoided costs due to dealing with potential patient harm. Alerts include dose adjustments for patients with deteriorating conditions and are first screened by the pharmacist before the physician is contacted. Future hospitals will include the physician order entry.
Code: MED
14. Mutter M. One hospital's journey toward reducing medication errors. Jt Comm J Qual Safety. 2003;29(6):279-288.
Valley Hospital focused on reducing medication errors beginning in 1994. Tracking and trending errors including near misses led to the Employee Occurrence Interview Form, new procedures and exploring technology solutions. Lessons learned included the importance of continued vigilance over complacency with success, achieving long-term goals required achieving short-term goals and that there is no one solution to reducing all error types.
Refs: 8 / Code: GEN; MED
15. Pape TM. Applying airline safety practices to medication administration. MedSurg Nurs. 2003;12(2):77-93.
This study measured two targeted interventions to improve medication administration safety by reducing distractions and found that training and a symbol (in this case a vest) significantly reduced the number of d distractions in administration. A discussion of the types of system failures leading to error is included.
Refs: 37 / Code: GEN; ERG; MED
16. Popp PL. How will disclosure affect future litigation?. J Healthc Risk Manag. 2003;23(1):5-9.
Communication should focus on the patient's care and treatment plan before answering questions about the system that led to the error. Describing a mock trial examining both disclosure and non-disclosure, the latter resulted in significant damages awards. The article closes with using disclosure to augment causation defenses.
Refs: 13 / Code: DIS; REL
17. Salgado CD, Farr BM. MRSA and VRE: preventing patient-to-patient spread. Infect Med. 2003;20(4):194-200.
Beginning with the epidemiology of the staphylococcus aureus and enterococcus organisms, the author discusses how they are spread and methods of control and prevention of resistance. Washing hands, changing gown, and isolating colonized patients are part of a solution which will result in significant financial savings to an institution. Houston in "Editorial comment: the lessons of history" pg 198 calls for a change in health care worker behavior in order to reduce infections.
Refs: 43 / Code: BUS; INF
18. Unruh L. Effect of LPN reductions on RN patient load. J Nurs Admin. 2003;33(4):201-208.
This study measured the percent change in RN, LPN, and licenses nurse staffing from 1991-2000 in Pennsylvania hospitals by examining both patient load and skill mix. Results include that number of FTE LPNs fell 29% while the total nursing staff increased 2% and that patient load increased 9% for RNs and 37% for LPNs. The authors recommend considering the role of both RNs and LPNs in the nursing process, improving efficiencies in the nursing processes, and maintaining an adequate RN workforce.
Refs: 40 / Code: ADM
19. Wang SJ, Middleton B, Prosser LA, et al. Cost-benefit analysis of electronic medical records in primary care. Am J Med. 2003;114(5):397-403.
This study found that over a five-year period, the net benefit was $86,000 per provider and accrued primarily from savings in drug expenditures, improved utilization of radiology tests, better capture of chargers and decreased billing errors. Both system and induced costs were considered and non-financial benefits, such as improved quality of care and reduced medical errors are noted.
Refs: 54 / Code: MED
20. Way LA, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237(4):460-469.
This study found that errors leading to laparoscopic bile duct injuries were due to misperceptions rather than skill, knowledge or judgement. This illustrates both the complexity of human error and that automatically attributing technical complications to behavioral factors may be incorrect. The discussion includes heuristic processes, confirmation bias and the importance of system changes over pure individual education.
Refs: 39 / Code: ERG; SUR
21. Young D. Patient safety is primary job for Missouri pharmacist. Am J Health-Syst Pharm. 2003;60(9):866-868.
Description of the role and responsibilities of the patient safety officer at Missouri Baptist Medical Center, including new programs, a blame-free culture, and involvement of patients in the system of care.
Code: ADM
Copyright 2003 National Patient Safety Foundation®
compiled by Holly Ann Burt for
the National Patient Safety Foundation®
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