Journal of patient safety
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Journal of patient safety · Mar 2017
Addressing Patient Safety in Rapid Response Activations for Nonhospitalized Persons.
Rapid response teams (RRTs) have been widely accepted as useful adjuncts to the care of inpatients with unanticipated emergencies. One study suggested that leadership of such teams could be assigned to midlevel providers, especially when nonhospitalized person (NHP)-related emergencies occur. However, in our tertiary medical center, a critical care medicine (CCM) physician always leads all RRT events including those related to NHPs. ⋯ Nonhospitalized patients requiring RRT activation often have complex pre-existent illnesses. A standardized team composition for both inpatients and NHPs in crisis is an appropriate administrative structure enhancing patient safety in hospitals where ambulatory and inpatient facilities are combined.
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Journal of patient safety · Mar 2017
Integrating Data From the UK National Reporting and Learning System With Work Domain Analysis to Understand Patient Safety Incidents in Community Pharmacy.
To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting. ⋯ Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.
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Journal of patient safety · Dec 2016
Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana.
This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana. ⋯ This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.
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Journal of patient safety · Sep 2016
Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department.
Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events. ⋯ Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.
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Journal of patient safety · Jun 2016
Ambulatory Computerized Prescribing and Preventable Adverse Drug Events.
Adverse drug events (ADEs) represent a significant cause of injury in the ambulatory care setting. Computerized physician order entry reduces rates of serious medication errors that can lead to ADEs in the inpatient setting, but few studies have evaluated whether computerized prescribing in the ambulatory setting reduces preventable ADE rates in ambulatory care. ⋯ The implementation of computerized prescribing in the ambulatory setting was not associated with any change in preventable ADEs but was associated with a decrease in potential ADEs at Indianapolis but an increase at Boston, although the absolute rate of ADEs was much lower in Boston.