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Medication Safety in the Neonatal Intensive Care Unit: Big Measures for Our Smallest Patients. J Perinat Neonatal Nurs 2017; 31:15-19. [PMID: 28121754 DOI: 10.1097/jpn.0000000000000230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McElroy LM, Khorzad R, Rowe TA, Abecassis ZA, Apley DW, Barnard C, Holl JL. Fault Tree Analysis. Am J Med Qual 2016; 32:80-86. [PMID: 26646282 DOI: 10.1177/1062860615614944] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The purpose of this study was to use fault tree analysis to evaluate the adequacy of quality reporting programs in identifying root causes of postoperative bloodstream infection (BSI). A systematic review of the literature was used to construct a fault tree to evaluate 3 postoperative BSI reporting programs: National Surgical Quality Improvement Program (NSQIP), Centers for Medicare and Medicaid Services (CMS), and The Joint Commission (JC). The literature review revealed 699 eligible publications, 90 of which were used to create the fault tree containing 105 faults. A total of 14 identified faults are currently mandated for reporting to NSQIP, 5 to CMS, and 3 to JC; 2 or more programs require 4 identified faults. The fault tree identifies numerous contributing faults to postoperative BSI and reveals substantial variation in the requirements and ability of national quality data reporting programs to capture these potential faults. Efforts to prevent postoperative BSI require more comprehensive data collection to identify the root causes and develop high-reliability improvement strategies.
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Symons VC, McMurray A. Factors influencing nurses to withhold surgical patients’ oral medications pre- and postoperatively. Collegian 2014; 21:267-74. [DOI: 10.1016/j.colegn.2013.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C, Mehrotra S. Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res 2014; 193:88-94. [PMID: 25277361 DOI: 10.1016/j.jss.2014.08.062] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 08/15/2014] [Accepted: 08/28/2014] [Indexed: 11/30/2022]
Abstract
Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.
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Affiliation(s)
- Zachary A Abecassis
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Lisa M McElroy
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ronak M Patel
- Division of Sports Medicine, Illinois Bone and Joint Institute, LLC, Morton Grove, Illinois
| | - Rebeca Khorzad
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Charles Carroll
- Department of Orthopaedic Surgery, NOI NorthShore Orthopedics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sanjay Mehrotra
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Rassweiler MC, Mamoulakis C, Kenngott HG, Rassweiler J, de la Rosette J, Laguna MP. Classification and Detection of Errors in Minimally Invasive Surgery. J Endourol 2011; 25:1713-21. [DOI: 10.1089/end.2011.0068] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
| | | | | | | | - Jean de la Rosette
- Department of Urology, AMC University of Amsterdam, Amsterdam, The Netherlands
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Asdigha MN. Improving Safety Throughout the Medication Use Process in a Neonatal Intensive Care Unit. Hosp Pharm 2006. [DOI: 10.1310/hpj4111-1067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Safety is the top priority for our institution. Safety has been reinforced since it became a priority of federal and state governments, the Institute for Safe Medication Practices (ISMP), and accrediting bodies (eg, the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], the National Committee for Quality Assurance). Neonatal practice has required additional attention because of the nature of the specialty and the high-risk drugs and patients in this practice area. Our institution created several multidisciplinary teams to address deficiencies in our medication use process. Each team had a member from the nursing staff, neonatology staff, nurse practitioner group, and a clinical pharmacy specialist; the neonatal intensive care nurse manager and pharmacy manager were ad hoc members. The systems involved defining and standardizing prescribing practices and processing and administration of medications. This paper is a description of changes made in a hospital medication use system without direct evaluation of the implementation of the changes. All the changes were successfully implemented within a 10-month period (September 2004 through June 2005) that encompassed 7 steps, including the elimination of the rule-of-6 method of drug preparation and administration, and utilization of an infusion device with decision-support software (smart pump).
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Satava RM. The nature of surgical error A cautionary tale and a call to reason. Surg Endosc 2005; 19:1014-6. [PMID: 16027984 DOI: 10.1007/s00464-005-8108-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 03/12/2005] [Indexed: 10/25/2022]
Abstract
Errors and "patient safety" have taken on monumental importance for surgery. Like all things new, there is an initial over-reaction before a return to a balanced perspective. The current response to the global interest in error has been to seize on the latest reports that are focusing on the "systemic nature" of errors, which is also being referred to as "the new look." There has been an unintentional ignoring of the actual error, referred to as the coface error, that the surgeon commits. It is time to put the approach to errors into perspective and redefine errors within the context of the surgical community, which can result in a balance of the surgeon's position in regard to systemic and personal responsibility.
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Affiliation(s)
- R M Satava
- Defense Advanced Research Projects Agency (DARPA-DSO), Arlington, VA 22203, USA.
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Cuschieri A. Reducing errors in the operating room: surgical proficiency and quality assurance of execution. Surg Endosc 2005; 19:1022-7. [PMID: 16027982 DOI: 10.1007/s00464-005-8110-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 05/12/2005] [Indexed: 01/10/2023]
Abstract
Technical operative errors cause surgical operative morbidity and adversely affect the clinical outcome of patients. Surgical proficiency thus underpins good and safe practice. In this context, standardization of endoscopic surgical operations and their execution are essential for the procurement and maintenance of quality assurance in endoscopic surgical practice. There is no clash between individual- (surgical proficiency) and system-based defense systems in the prevention of surgical errors--both underpin safe surgical practice. Although more human factors and surgical research are needed, it is possible to formulate and adopt a surgical error reduction system for endoscopic operations based on standardization of operations, surgical operative proficiency, and human reliability assessment and its related clinical counterpart, observational clinical human reliability assessment.
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Affiliation(s)
- A Cuschieri
- School of Advanced University Studies of S'Anna, Pisa P.zza dei Martiri della Libertà n. 33, 56127 Pisa, Italy.
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Preprinted Prescription Forms Decrease Incomplete Handwritten Medication Prescriptions in a Neonatal Intensive Care Unit. J Patient Saf 2005. [DOI: 10.1097/01209203-200506000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Sharp-end, frontline human error occurs close to the delivery of patient care. The purpose of this article is to examine the mechanism of human error and cognition, and to explore the antecedents, attributes, and consequences of frontline human error. Fallible decision-making and actions leading to patient injury are explicated in a case study. The discussion includes strategies for preventing patient injury by refining system flaws.
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Affiliation(s)
- Diane Kennedy
- School of Nursing, University of Kansas, Kansas City, KS 66160, USA.
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