Approximately 10% of admissions to acute-care hospitals are associated with an adverse event. Analysis of incident reports helps to understand how and why incidents occur and can inform policy and practice for safer care. Unfortunately our capacity to monitor and respond to incident reports in a timely manner is limited by the sheer volumes of data collected. In this study, we aim to evaluate the feasibility of using multiclass classification to automate the identification of patient safety incidents in hospitals. Text based classifiers were applied to identify 10 incident types and 4 severity levels. Using the one-versus-one (OvsO) and one-versus-all (OvsA) ensemble strategies, we evaluated regularized logistic regression, linear support vector machine (SVM) and SVM with a radial-basis function (RBF) kernel. Classifiers were trained and tested with
Baines, R., Langelaan, M., Bruijne, M. de, Spreeuwenberg, P., Wagner, C. How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time. BMJ Quality & Safety: 2015, 24(9), 561- ...
RESULTS: In the 2006 KID, 22.3% of pediatric inpatients had 1 chronic condition, 9.8% had 2 chronic conditions, and 12.0% had ≥3 chronic conditions. The overall medical error rate per 100 discharges was 3.0 (95% confidence interval [CI]: 2.8-3.3); it was 5.3 (95% CI: 4.9-5.7) in children with chronic conditions and 1.3 (95% CI: 1.2-1.3) in children without chronic conditions. The medical error rate per 1000 inpatient days was also higher in children with chronic conditions. The association between chronic conditions and medical errors remained statistically significant in logistic regression models adjusting for patient characteristics, hospital characteristics, disease severity, and length of stay. In the adjusted model, the odds ratio of medical errors for children with 1 chronic condition was 1.40 (95% CI: 1.32-1.48); for children with 2 conditions, the OR was 1.55 (95% CI: 1.45-1.66); and for children with 3 conditions, the OR was 1.66 (95% CI: 1.53-1.81). ...
These data from a nationally representative dataset provide some of the first data regarding the general problem of hospital-reported medical errors in pediatric inpatients. By using a nationally representative inpatient sample, it is possible to discuss patterns in the broad group of pediatric patients. We now have an understanding that hospital-reported medical error in hospitalized children is a relatively rare event occurring in ,3% of hospital discharges. This rate has increased from 1988 to 1991, but remained stable from 1991 to 1997. Furthermore, children with increasingly complex medical care have higher medical error rates, which is consistent with data derived from studies on adult patients. Children with medical errors also had higher associated LOS and mortality rates throughout the years studied. Therefore, this work primarily provides an important reference point for subsequent and more specialized studies of specific patient groups such as children with chronic illnesses who may ...
Both the IOM and QuIC reports emphasize the importance of collaboration between federal, state, and private-sector stakeholders. According to the National Academy for State Health Policy (NASHP), states responded to the IOM report with 45 bills related to medical errors, of which eight had been enacted by July. Only 20 states, however, have mandatory reporting programs related to patient safety.. "States are looking for guidance," says Jill Rosenthal, an NASHP policy analyst. "Theyre interested in standardization, but they dont want to see that developed at the federal level without state input." Standardization, both in collecting data on medical errors and in promulgating best practices, is a prerequisite for preventing errors from reoccurring.. Even states with relatively robust mandatory reporting systems are struggling to define for providers what constitutes a medical error. The Pennsylvania Department of Health, for example, sent licensed health care facilities a list of questions and ...
According to some observers, the CDC instructs doctors to only list medical conditions as the cause of death, and its coding system does not account for medical mistakes whether diagnostic errors, poor judgment or communication breakdowns. However, the CDC notes that complications arising from medical treatment are listed on death certificate, but only the condition that was being treated is listed as the underlying cause of death.. As a result, the public is not aware of the impact of medical errors, and the authors of the study are calling for death certificates to specifically ask if a complication that could have been prevented contributed to the death. The failure to report medical errors ultimately hinders research that could be helpful in reducing the number of deaths by providing more resources aimed at patient safety.. Ultimately, whether the study will prompt the CDC to include medical errors on its annual list of the leading causes of death remains to be seen. In the meantime, ...
Patient safety is defined as the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of healthcare,1 while a patient safety incident is defined as any unintended event or hazardous condition resulting from the process of care, rather than due to the patients underlying disease, that led or could have led to unintended health consequences for the patient or healthcare processes linked to safety outcomes.2Patient safety research has traditionally focused on hospital-based specialist settings, but there is growing evidence that patient safety in primary care can also be problematic.3-5 Patient safety incidents related to prescription of medication, diagnostic errors and communication failures are frequently encountered in primary and secondary care (ranging from 2% to 10% of consultations).6-9 These safety incidents might be more common or severe in vulnerable patient groups such as older patients with two or more long-term conditions (known as ...
Using medical data collected over an eight-year period, patient safety experts at Johns Hopkins have calculated that medical errors are now the third leading cause of death in the US. At more than 250,000 deaths per year attributed to medical mistakes, this number exceeds the Center for Disease Control and Preventions (CDC) third most common cause of death - respiratory disease - which is responsible for almost 150,000 deaths each year.. According to the researchers, the CDCs data does not reflect medical errors, which are often not listed on the death certificate. The authors of the paper - which was published in The BMJ - are urging regulators to update the system used to classify cause of death on these documents.. "Incidence rates for deaths directly attributable to medical care gone awry havent been recognized in any standardized method for collecting national statistics," said Dr. Martin Makary, professor of surgery at the Johns Hopkins University School of Medicine and an authority on ...
The quality/patient safety department assists hospitals with meeting The Joint Commissions National Patient Safety Goals, addressing CMS patient safety-related regulations, ensuring patient satisfaction, and improving the overall quality of care.
The quality/patient safety department assists hospitals with meeting The Joint Commissions National Patient Safety Goals, addressing CMS patient safety-related regulations, ensuring patient satisfaction, and improving the overall quality of care.
|p|A study conducted by UC-San Francisco and eight other institutions found that improving verbal and written communication between providers resulted in a 30% decline in patient harm from medical errors. According to researchers, medical errors are the third leading cause of death in the U.S. |/p|
The alerts provide clinicians the opportunity to learn about root causes of errors. To effectively avoid future errors that can cause patient harm, improvements must be made on the underlying, more-common and less-harmful systems problems5 most often associated with near misses. Disclosure of medical error. Near Miss Error Hebert PC, Levin AV, Robertson G. How to handle apologies effectively is a key issue for error disclosure. Previously, it was assumed that most medical errors were due to providers who were either incompetent or lazy. The system returned: (22) Invalid argument The remote host or network may be down. news Multiple barriers inhibit disclosure, ranging from fear of malpractice to shame and embarrassment from admitting to a patient that one has made an error. In most cases, disclosure does not appear to stimulate lawsuits, and may in fact make lawsuits less likely. Mandatory and voluntary reporting systems differ in relation to the details required in the information that is ...
I sit on an advisory board for our state that focuses on medical errors. Medical errors can occur in many forms including prescribing medications in people with allergies, wrong dosages, wrong site su...
Patient safety at US hospitals not getting better despite efforts to improve patient care reduce infection rates and decrease occurrence of preventable medical errors
After a medical error, hospitals often prevent doctors from talking to patient families. Now new research shows that everybody - patients, doctors and the hospital - benefits when communication is encouraged after a medical mistake.
Porte, P.J., Smits, M., Verweij, L.M., Bruyne, M.C. de, Vleuten, C.P.M. van der, Wagner, C. The Incidence and Nature of Adverse Medical Device Events in Dutch Hospitals. A Retrospective Patient Record Review Study. Journal of Patient Safety: ...
MERCI (Medical Error Reduction and Certification, Inc.) is a patient safety training enterprise designed specifically to serve hospitals in need of methodology, validation, and ongoing auditing to reduce procedural medical errors and improve patient safety. Achieving these objectives not only improves patients lives and health, but also has a major positive financial impact on the bottom line in todays health care system. When thorough training, maintenance of skills, and adherence to industry best practices are rigorously implemented, a dramatic reduction in preventable errors can be achieved. To learn more about MERCI, visit www.merciprogram.com ...
2 CE hrs of Medical Errors approved in Florida only $6. Medical Errors CE course is approved in Florida for PT, RN, LPN, PTA, RT, Dietitians and Nutrition Counselors. Immediate reporting of CE hours to CEBroker.
Program Services: Online Continuing Education and Home Study, Florida Behavioral Health Laws and Rules,Issues In Supervision,Approved CE Provider with American Psychological Association, and National Board for Certified Counselors and provider of US DOT Substance Abuse Qualification Training and National examination for substance abuse professionals, AAMFT 30 Hour approved clinical supervision training. Home Study, Online Courses and Live Florida Seminars. Found at: http://www.programservices.org
Since the Institute of Medicine (IOM) report "To Err is Human" in 1999, patient safety and education to prevent medical errors has been critical to healthcare. Additionally, regulatory and accreditation bodies have set standards to improve the quality of health care organizations to help provide safe patient care across all settings. Despite numerous efforts, medical error rates do not seem to be improving. For example, in 2000, the IOM report stated that up to 98,000 deaths occur as a result of medical errors.1 More recently, Makary and Daniel state that the numbers were actually underestimated and report a mean rate of death from medical error of 251,454 a year. This would make medical errors the 3rd most common cause of death in the United States for 2013.2 ...
Since the researchers looked retrospectively at the discharge summaries, they were able to see if test results reported after discharge called for a change in the patient treatment plan or management. "We found that a huge number -- 72 percent -- of test results requiring treatment change were not mentioned in discharge summaries. So an outpatient provider likely would not even have known that the results of these tests needed to be followed up. In the patient safety arena, this is what you call a fumbled handoff - and it leads to medical errors." said Martin Were, M.D., MS., first author of the study. Dr. Were is a Regenstrief Institute investigator and an assistant professor of medicine at the IU School of Medicine.. While it is easy to blame busy health-care providers for poor quality of discharge summaries, the problem largely reflects a failure in the system, according to Dr. Were. Similarly, in its seminal report To Err is Human, the Institute of Medicine advocates for changes in ...
We found that a huge number -- 72 percent -- of test results requiring treatment change were not mentioned in discharge summaries. So an outpatient provider likely would not even have known that the results of these tests needed to be followed up. In the patient safety arena, this is what you call a fumbled handoff - and it leads to medical errors." said Martin Were, M.D., MS., first author of the study. Dr. Were is a Regenstrief Institute investigator and an assistant professor of medicine at the IU School of Medicine ...
Nightmare stories of nurses giving potent drugs meant for one patient to another and surgeons removing the wrong body parts have dominated recent headlines about medical care. Lest you assume those cases are the exceptions, a new study by patient safety researchers provides some context.. Their analysis, published in the BMJ on Tuesday, shows that "medical errors" in hospitals and other health care facilities are incredibly common and may now be the third leading cause of death in the United States - claiming 251,000 lives every year, more than respiratory disease, accidents, stroke and Alzheimers.. ...
Patient safety initiatives aimed at addressing the potential for adverse events and medical errors are being implemented in many labor and delivery departments. PROMPT Flex is ideal for addressing high risk, low frequency events and reducing complications. The versatile and modular design provide the user with a comprehensive experience in all stages of birth and complexity. Suited for all learners in both professional education and healthcare providers ...
Alex Christgen, executive director for the Center for Patient Safety, joins Quality Talk host Jodie Jackson Jr. to talk about eliminating medical errors.
CHICAGO, ILL-Hospital administrators will begin to receive information about reducing medical errors from the American Hospital Association (AHA) and their state hospital associations. AHA News reported that a video titled "Beyond Blame" and the report "Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine" have been sent to hospitals across the country. The video presents a series of errors from the viewpoint of the providers involved, and the report presents profiles of institutions that have made commitments to patient safety and medical error reduction. The profiles reflect some of the more innovative efforts currently in this area. ...
It is not intended as a substitute for professional healthcare. J Med Ethic Hist. 2009;3(Suppl 1):60-9.10. State legislatures can also provide for safer care through laws designed to improve the nursing workplace environment. Medication Errors Articles Implement protocols for vulnerable populations (elderly, pediatric, obese patients). These results have been shared to prevent similar sentinel events from occurring and to protect patients. SPSS software version 16 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis and P values less than 0.05 were considered significant.ResultsAll questionnaires were returned to the researchers after being Generated Sat, 22 Oct 2016 05:13:31 GMT by s_wx1157 (squid/3.5.20) click site The key to reducing medical errors is to focus on improving the systems of delivering care and not to blame individuals. Department of Health and Human Services National Institutes of Health Page last updated: 05 October 2016 ANA HomeAbout OJINFAQsAuthor ...
Serious medical errors don t just affect the health of the patient, they can quickly destroy the patient s relationship with his or her doctor, too, experts say
Our study has a number of strengths: the large, representative sample drawn from Trusts in different regions and of different size and teaching status; our use of problem in care rather than the commonly used adverse event to minimise the risk of overlooking errors of omission; and the various measures to standardise data collection and ensure high quality record review.. Nonetheless, several limitations need to be considered. First, medical records may not document all problems in care, though this limitation applies to all RCRR studies, including ones that have generated previous estimates of preventable hospital deaths. Second, the estimates of life expectancy were dependent on reviewers judgement, a notoriously difficult task. Third, RCRR studies are often criticised because of the poor reliability of the reviewers judgements. We used a number of approaches to improve reliability and obtained a moderately strong inter-rater agreement that compared favourably with previous studies. Some ...
Despite the efforts of healthcare providers, medical error rates in communities, hospitals, and homes remain high. Patients and families pay for errors through
AbstractMedical errors training is an important yet often overlooked aspect of medical education. A medical errors educational session was developed for rotating medical students (MSs) with prospective analysis of the educational tool. Students completed the same 12-question test before and after th
SheKnows Parenting shares advice from an expert on how to ensure your child does not become a statistic of a hospital medical error.
THE EFFECTS OF COMPUTER SIMULATION ON REDUCING THE INCIDENCE OF MEDICAL ERRORS ASSOCIATED WITH MASS DISTRIBUTION OF CHEMOPROPHYLAXIS AS A RESULT OF A BIOTERRORISM EVENT
According to a recent study, medical errors kill an estimated 250,000 Americans each year, making it the third leading cause of death in the U.S.
A Young Cancer Patient Recovering At Home From Medical Error. A young cancer patient recovering at home from a bone marrow transplant died.
Keep detailed patient records. Begin by recording each decision thats made and the reasons why. This is especially important if a patient has taken some persuading about a particular course of treatment. It might seem laborious at the time, but these notes can be used as evidence if any questions or issues arise in future to show what happened when and why. If notes are sufficiently detailed, they can also help with memory recall about the patient or client in question.. Say sorry. Mistakes happen and when they do, a genuine apology goes a long way to appeasing a disgruntled patient or customer. Try to demonstrate genuine reflection and an understanding of the lessons learned, as well as providing a detailed explanation of what went wrong in the first place. If necessary, offer reassurances that the mistake wont happen again, perhaps demonstrating a change in procedures or policies as a result.. Encourage honesty. Try to foster an open culture within your team so your staff feel able to admit ...
What separates a mistake from medical malpractice is often not the areas in which they occur, but the degree to which the mistakes were avoidable.
Dana Carvey felt quite differently, and subsequently, he filed a $7.5 million lawsuit against the surgeon and the hospital.2) Doctors Perform Heart Surgery on Wrong Patient It would be quite easy I was looking for something, anything, to make sense of those final five months. Medical Mistakes Articles Marys Hospital in Madison, WI, in the summer of 2006 when 16-year-old Jasmine Gant was admitted to give birth. Fatal Medication Error Stories At some point in the morning, the nurse who reported understanding the intended dosing, made an error in entering the information into the IV pump. The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. http://dlldesigner.com/medication-error/nurses-medical-error-gov.php What I learned was that no amount of industry knowledge on my part, no amount of elder advocacy and no keen interest in Medicare could have saved Tootsie from a textbook The initial ...
Do all employees in healthcare understand how their jobs link to patients in some way? If they do, then they are more likely to know the importance of service excellence. Does every leader, physician, and employee know the statistic that preventable medical errors are the third leading cause of death in the United States?
The Institute for Healthcare Improvement and the National Patient Safety Foundation (IHI) Lucian Leape Institute and NORC at the University of Chicago...
In December 1999, the U.S. Federal Governments Institute of Medicine issued a report entitled, To Err is Human: Building a Safer Health System. This report cited between 44,000 and 98,000 deaths every year due to medical errors. While these numbers are disputed by some, they would make medical errors the 8th leading cause of death, ahead of breast cancer or AIDS.. Dialysis patient safety is a complex issue that involves highly specialized dialysis technology, staff training and turnover, cost pressures, reporting of problems, oversight and regulations, water purification, dialyzer reuse, medication errors, patient compliance, patient education, primary care, prevention, vascular access, infection, location and layout of dialysis units, and the increased age and comorbidities of the ESRD population. Patient safety and injury prevention are most effective when it involves everyone in the healthcare delivery scheme. Towards that end, RenalWEB has accumulated this list of resources that addresses ...
The patient safety movement in healthcare is beginning to openly acknowledge the need to support the human side of adverse medical events in conjunction with evidence-based improvement initiatives. While medical literature has sporadically reported on the emotional impact of adverse events on healthcare professionals, little has been documented on the implementation of support services following these events. This article describes an adverse medical event where open communication and apology catalysed the development and implementation of a structured peer support service for care providers at the Brigham and Womens Hospital following adverse events. The Peer Support Service bypasses the stigmas that limit the utilisation of formal support services and offers care providers a safe environment to share the emotional impact of adverse events while serving as a foundation for open communication and a renewal of compassion in the workplace. As the breadth of stressors impacting healthcare ...
An updated estimate says it could be at least 210, 000 patients a year - more than twice the number in the Institute of Medicines frequently quoted report
By Wanda MorrisImagine you wake up, with a foggy sense of relief, from a knee operation. In the six-month wait for surgery, you had almost grown used to the pain and loss of mobility. Now, you think, recovery begins.Your relief turns to stunned disbelief as you see the bandages on your left knee.
During the biopsy Rivers vocal cords reportedly seized -- slammed shut -- cutting off her air supply. Sources tell TMZ while they were trying to resuscitate her, her heart stopped ...
For expectant parents, the birth of a child is a long-awaited and anticipated event the culmination of which is meant to be a joyous and celebratory occasion. However, not all...
So said Dr Glenn D Braunstein, M.D., today, in Huffington Post while lamenting the fact that every year, one in 20 people are infected by staff, and 98,000 Americans die, because the medical profession still dont wash their hands. Dr Braunstein is unusual, in that hes speaking out. (Either that, or ... hes naive.) He rolled out the usual stories of Semmelweis, and also explains why official statistics are a gross under-estimate. Then of course, there is the thorny figure he doesnt discuss for deaths from preventable medical error (sorry "systems error - and that 2008 figure is out of date) and another death roll call from prescription drugs which beats that from heroin and cocaine combined. Add these three figures together - the annual death figure courtesy of the medical profession, explodes way beyond 300,000 deaths per year, just for USA alone. What is the total world wide ...
Illustration by Andre DaLoba. In our Johns Hopkins Health System, there can be considerable differences in the way we treat two patients with the same diagnosis. Often these differences are justified (see Hopkins Medicines special issue on precision medicine, Winter 2017). Other times this variation is based not on a patients special characteristics or what the data indicates or even a physicians intuition-but rather our own habits as practitioners.. Scholars of health care have a name for this phenomenon-unwarranted variation-and it is one of the most unrelenting problems in medicine. While estimates vary, unfounded variation in care adds up to as much as $600 billion in avoidable health care spending per year in the United States. Reducing this clinical variation is not just a cost-control measure: It is a necessary step toward better outcomes and more satisfied patients. Knowing that preventable medical errors are a leading cause of death in this country provides tremendous incentive to ...
Clinicians involved in medical errors are often referred to as "second victims" because they can experience persistent negative effects such as guilt, embarrassment, self-doubt and fear that can have serious consequences on their well-being, work performance and patient safety. Researchers conducted an electronic survey of 575 members of the American Society for Healthcare Risk Management, including risk managers, executives, patient safety officers, directors of quality and compliance officers, to ascertain how they would characterize the structure and performance of their provider support program, if a program was available. Investigators found that while 74 percent of health care organizations maintain a support ...
The Office of the National Coordinator (ONC) for Health Information Technology April 11 announced requirements and registration details for a new