BMJ quality & safety
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BMJ quality & safety · Nov 2012
ReviewDiagnostic errors in the intensive care unit: a systematic review of autopsy studies.
Misdiagnoses may be an underappreciated cause of preventable morbidity and mortality in the intensive care unit (ICU). Their prevalence, nature, and impact remain largely unknown. ⋯ Our data suggest that as many as 40,500 adult patients in an ICU in USA may die with an ICU misdiagnoses annually. Despite this, diagnostic errors receive relatively little attention and research funding. Future studies should seek to prospectively measure the prevalence and impact of diagnostic errors and potential strategies to reduce them.
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BMJ quality & safety · Nov 2012
Adverse drug events caused by serious medication administration errors.
To determine how often serious or life-threatening medication administration errors with the potential to cause harm (potential adverse drug events) result in actual harm (adverse drug events (ADEs)) in the hospital setting. ⋯ Unintercepted potential ADEs at the medication administration stage can cause serious patient harm. At hospitals where 6 million doses are administered per year, about 4000 preventable ADEs would be attributable to medication administration errors annually.
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BMJ quality & safety · Nov 2012
Comparative StudyAvoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.
Handover of patient information represents a critical time period during a patient's hospitalisation. While recent guidelines promote standardised communication during these patient care transitions, significant variability in structure and practice persists among hospitals and providers. ⋯ Standardisation of information transmitted during patient handovers through the use of a structured, web-based application led to consistent transfer of vital patient information and was associated with improved resident confidence and fewer perceived near-miss events on call.
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BMJ quality & safety · Nov 2012
Interruption handling strategies during paediatric medication administration.
Interruptions are a part of many hospital settings. During medication administration, interruptions have been shown to lead to medication errors. Understanding interruption management strategies during medical management could lead to the design of interventions to reduce and mitigate related errors. ⋯ Paediatric nurses have developed sophisticated strategies to manage interruptions and maintain patient safety and work efficiency during medication administration. To support a more resilient healthcare system, interruption management strategies should be supported through process, task support tools and education.