Showing posts with label medication errors. Show all posts
Showing posts with label medication errors. Show all posts

Wednesday, March 2, 2011

e-Autopsy: Kaiser Hospitals Dig In to Data to Assess Mortality

You've heard the macabre joke that hospitals and doctors "bury their mistakes." Well, here's an interesting twist: At Kaiser Permanente hospitals in Southern California, doctors are doing precisely the opposite. They're rolling back time in the death process – exhuming their unknown mistakes so to speak – to see what, if anything, they can learn in order to save similar patients the next time around.

But they're not doing it the old way through invasive autopsies. Those are expensive, increasingly unpopular with families, forbidden by some religions, and often don't reveal that much about errors in the process of hospital care.

Kaiser has a new concept, the e-Autopsy.

Kaiser's hybrid manual and electronic mortality review uses storytelling and specialists' scrutiny to study medical charts of patients who died in the hospital. The process builds a precise timeline of what happened. The goal is to prevent death and/or improve end-of-life care by looking for places to improve—from ambulatory settings prior to admission to the inpatient bedside.

via healthleadersmedia.com

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Tuesday, March 1, 2011

HHS Releases National Plan to Improve Health Literacy | HHS.gov

Today, the United States Department of Health and Human Services released The National Action Plan to Improve Health Literacy aimed at making health information and services easier to understand and use. The plan calls for improving the jargon-filled language, dense writing, and complex explanations that often fill patient handouts, medical forms, health web sites, and recommendations to the public.

According to the report, efforts to improve the health literacy skills of both the public and health professionals are needed to achieve a health literate society—a critical need as health reform generates more demand for consumer and patient information that is easy-to-understand and culturally and linguistically appropriate.

According to research from the U.S. Department of Education, only 12 percent of English-speaking adults in the United States have proficient health literacy skills. The overwhelming majority of adults have difficulty understanding and using everyday health information that comes from many sources, including the media, web sites, nutrition and medicine labels, and health professionals.

“Health literacy is needed to make health reform a reality,” said HHS Secretary Kathleen Sebelius. “Without health information that makes sense to them, people can’t access cost effective, safe, and high quality health services. But, HHS can’t do it alone,” she added. “We need payers and providers of health care services to communicate clearly and make the necessary changes to improve their communication with consumers, patients, and beneficiaries. Today’s plan is only the beginning of a long-term process with our many partners in all sectors that we hope will result in a society that encourages people to live longer, healthier lives.”

via hhs.gov

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Thursday, February 24, 2011

Nearly 60% of paid home caregivers make medication errors, study finds - McKnight's Long Term Care News

One-third of paid caregivers who work for clients who live in their own homes had difficulty reading and understanding health-related information and instructions. Furthermore, 60% of them made medication errors involving their clients, according to Northwestern University researchers, who say the study is the first of its kind.

Investigators at the university recruited 100 paid, non-family caregivers in the Chicago area and evaluated their literacy with health-related tasks and knowledge. While researchers emphasized that the majority of caregivers are good people who are trying to support their families, medication-error levels are a serious cause of concern.

They found that most paid caregivers are women with an average age of 50 years old. Many are foreign born with limited schooling. They are usually paid about $9 an hour, though almost one-third earns less than minimum wage.

via mcknights.com

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Saturday, February 19, 2011

LegalNursingConsultant.com, Medical Legal Resources, Nursing Entrepreneurs

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This website is intended to be a resource for Legal Nurse Consultants, Attorneys looking to use their services, and nurses looking to enter the field of Legal Nurse Consulting. On our site you'll find a directory of LNCs by state and specialty.

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Legal Eagles: Put nursing, law and business together and what do you get? The exciting field of legal nurse consulting! By Barbara Marquand, Minoritynurse.com:"Gloria Blackmon, RNC, BSN, LNC, LNHA, never met the young man who lost his legs, but after reading over his medical records, the compassion she felt for him was as strong as if he had been her own patient. The young man had been living in an intermediate care facility for developmentally disabled adults when circulation problems in his legs became so severe that both limbs had to be amputated. His parents sued the facility and it was Blackmon’s job, as a legal nurse consultant for their attorney, to review the records and determine if they had a valid case."
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Combine Nursing and the Law through Legal Nurse Consulting, Meghan Persichino, RN, BSN, LNC, Nursingspectrum.com:"Nursing and the law: While some nurses think only of the possibility of being sued, others understand the power of this partnership in improving health. These forward-thinking nurses are blazing a trail as legal nurse consultants (LNCs). An Emerging Role Nurses have been working alongside attorneys for almost 25 years, if not more. These nurses went by titles such as "nurse paralegal," "medical litigation consultant," and other monikers. In some instances, they combined the duties of both the paralegal and nursing professions; there was no uniform role definition."
http://nsweb.nursingspectrum.com/cfforms/GuestLecture/nursingandlaw.cfm

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Switching Gears Becoming a Legal Nurse Consultant Diane Barnet, RN, BA, Nursingspectrum.com:"It sounded so easy. On the strength of a guest opinion piece I wrote about the nursing shortage for The Dallas Morning News, an attorney contacted me in the spring of 2002. I was suspicious. What would a lawyer want from me? “I’d like to send you a case,” he offered. “But I don’t have any legal background,” I protested. “That doesn’t matter,” he replied. “You can write.”"
http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=12518

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Legal Nurse Consultant by Sara Courson, BSN, Career Development, PA State Nurses Association:"Legal Nurse Job Search Quick Links: What is a Legal Nurse Consultant Educational Requirements Specialty Certification Salary Ranges Entry Advice Associations Publications Schools References About the Author."
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Legal Consulting by Nurses, By Joy Collins, RN, BSBA, CLNC, LNCC, Wild Iris Medical Education, Inc.:"Nurses have been assisting attorneys with their medically related cases for far longer than is generally realized. It is only lately that the sub-specialty of legal nurse consulting has become a recognized field of nursing that the media has thrust into the mainstream. As far back as the 1980s (and probably earlier), nurses and other medical professionals were assisting the legal world to arrive at a fair settlement by moving through the quagmire of medical records and jargon that we nurses take for granted."
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http://www.nursingceu.com/courses/244/index_nceu.html

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Medical Information, The Internet, and You By Janabeth Fleming Evans R.N., R.N.C., Doereport.com:" As a medical-legal consultant and Internet researcher I am asked every day to find authoritative medical literature references for a broad spectrum of topics. The information I am looking for may be used to support a claim, to debunk an expert theory, or to educate the attorney during the course of a case evaluation. Changes in the way medical information is stored, accessed, and retrieved have created a wealth of health care information. The Internet provides free access to a great deal of the medical literature, either in full text or citation/abstract format. Because anyone with access to the Web can establish a Web page, many medical sites contain little useful information, even though they may be visually appealing. For this reason, the quality of information available varies from very good to poor, and some sites even intend to mislead. It is important to search for peer reviewed information, from an authoritative source.
1275 Shiloh Road Suite 3130 Kennesaw, Georgia 30144
Phone: 770.805.0460 800.338.5954 Fax: 770.805.0430
Email: info@doereport.com
http://nursingexperts.doereport.com/20001130janabeth.php

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Friday, February 11, 2011

Medical News: Nursing Home Med Errors Vary by Form of Drug - in Geriatrics, General Geriatrics from MedPage Today

Residents in nursing and old age homes are four times as likely to get an incorrect dose of medication if it's in liquid rather than pill form, researchers reported.

In a study in 55 British homes, errors included such things as incorrect measurements and not shaking a suspension, according to David Phillip Alldred, PhD, of the University of Leeds in Leeds, England, and colleagues.

Errors also were more likely with inhalers and other drug formulations, compared with pills or tablets dispensed using a monitored dosage system, Alldred and colleagues reported online in BMJ Quality and Safety.

Monitored dosage systems -- also known as unit dose systems -- consist of a tray or cassette with compartments for one or more doses for a particular day and time and are intended to simplify the administration of medications for staff, the researchers noted.

But such systems can't be used for all medications -- liquids, among others -- and it's not clear that they are safer than delivering drugs from the manufacturer's own packaging, Alldred and colleagues noted.

via medpagetoday.com

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Monday, January 31, 2011

Institute For Safe Medication Practices

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NEW Standard Concentrations of Neonatal Drug Infusions
FDA and ISMP List of Drug Names with Tall Man Letters
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Wednesday, November 17, 2010

Children's Hospital launches 'zero errors' initiative

Reeling from the deaths of two children due to medication errors, the staff of Seattle Children's Hospital devoted Saturday to special training designed to prevent a recurrence of the tragedies.

"It's so very important that we never forget that we harmed these children," said Pat Hagan, president of Children's Hospital. "We were all devastated by this when it happened. It struck us at our core."

Hagan said the patient deaths have been a "great, great tragedy for these families," and "a profound tragedy" for the hospital staff.

"We never want to forget how this feels. That feeling is going to be what drives us to continue to find ways to improve what we do here," he said.

Over 550 doctors, nurses, pharmacists and other staff members gathered at Children's for a special Patient Safety Day to address the medication errors that caused two deaths over the past 18 months.

More than 28 patient safety sessions were held, including 11 devoted to medication safety.

But first, participants gathered together in the morning to remember the two small patients who died.

"How we emerge from this situation today and over the coming months will be the real test of us as an organization," said Thomas Hansen, the hospital's CEO. "As I look around this room, I'm confident that we have the best and brightest people to rise to this challenge."

He told the staff "we must strive for zero errors, this must be our promise."

The day's sessions included topics such as decreasing verbal orders and increasing the safety of verbal orders when they are necessary, standardizing medications located on care units, ordering, dispensing and administration of high-risk medications, interruptions, provider-to-provider hand-offs and communication, ambulance transport and patient safety training using simulation.

Hospital spokesperson Louise Maxwell said Children's also is fully cooperating with state investigations of the recent medication errors and has made a number of improvements to decrease the chance of errors.

The hospital has also initiated a re-evaluation of the entire medication delivery system and launched a detailed analysis to determine why usual safety processes failed in each of the medication error cases.

Hospital officals said Saturday's special training did not affect care for patients or others needing urgent or emergency services.

via seattlepi.com

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Tuesday, November 16, 2010

Hospital care fatal for some Medicare patients - USATODAY.com

An estimated 15,000 Medicare patients die each month in part because of care they receive in the hospital, says a government study released today.

The study is the first of its kind aimed at understanding "adverse events" in hospitals — essentially, any medical care that causes harm to a patient, according to the Department of Health and Human Services' Office of Inspector General.

Patients in the study, a nationally representative sample that focused on 780 Medicare patients discharged from hospitals in October 2008, suffered such problems as bed sores, infections and excessive bleeding from blood-thinning drugs, the report found. The federal Agency for Healthcare Research and Quality called the results "alarming."

"Reducing the incidence of adverse events in hospitals is a critical component of efforts to improve patient safety and quality care" in the U.S., the inspector general wrote.

The findings "tell us exactly what some of us have been afraid of, that we have not made much progress," said Arthur Levin, director of the independent Center for Medical Consumers and a member of an Institute of Medicine committee that wrote a landmark 1999 report on medical errors. "What more do we have to do to make sure that sick people can rest assured that they're not going to be harmed by the care they're getting?"

Among the findings in the report obtained by USA TODAY:

•Of the 780 cases, 12 patients died as a result of hospital care. Five were related to blood-thinning medication.

Two other medication-related deaths involved inadequate insulin management resulting in hypoglycemic coma and respiratory failure resulting from oversedation.

•About one in seven Medicare hospital patients — or about 134,000 of the estimated 1 million discharged in October 2008 — were harmed from medical care.

•Another one in seven experienced temporary harm because the problem was caught in time and reversed.

About 47 million Americans are enrolled in Medicare, a government health insurance program for people 65 and older and those of any age with kidney failure.

The adverse events found in the study weren't necessarily due to medical mistakes, said Lee Adler, a University of Central Florida medical professor who was involved in the study. For example, he said, an allergic reaction to a penicillin injection is an adverse event, but it's a medical error only if the patient's allergy was known prior to the shot.

Among the problems identified in the report were Medicare patients who had excessive bleeding following surgery or a procedure. For example, one patient had excessive bleeding after his kidney dialysis needle was inadvertently removed, which resulted in circulatory shock and an emergency insertion of a tube to allow breathing.

When the tube was removed the next day, the patient inhaled foreign material into his lungs and needed lifesaving medical help, the report said.

Peter Pronovost of Johns Hopkins University, co-author of the book Safe Patients, Smart Hospitals, said medical mistakes are "an enormous public- health problem."

"We spend two pennies trying to deliver safe health care for every dollar we spent trying to develop new genes and new drugs," Pronovost said. "We have to invest in the science of health care delivery."

via usatoday.com

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