جستجوی مقالات مرتبط با کلیدواژه « Medical Error » در نشریات گروه « پزشکی »

Medical mistakes cause injury to patients and raise the expenses of treatment and hospital stays. The current study aimed to identify medical errors in the field of gastroenterology and propose a prevention strategy.The study was carried out through a mixed method (quantitative, qualitative) in a sequential manner. In the first stage (quantitative), common errors in the department were identified. In the second stage (qualitative stage), data gathering was done by interviewing nurses and doctors. The collected data was analyzed using content analysis method and error prevention strategies were identified.The mean (standard deviation) score of patients in the departments were 66.28 (98.7), and the mean number of nurses was 4.83 (26.3). It was found that the most medical errors were not serious, and the most errors in drug registration were drug card registration (42.9%), drug preparation (38.1%), and drug prescription (33.3%). Medical errors resulting in severe complications due to incorrect patient identification accounted for 2% of the total errors. The suggested prevention strategies included: adjusting department supervision processes, ensuring proper training, enhancing patient education, and developing a culture of error reporting.The study's findings revealed a high frequency of errors that were largely benign and identified before they occurred. Nevertheless, given their potential to inflict harm, it is essential to implement effective error detection and reporting system.

Hospitals, as one of most important subsectors in human societies, are responsible for providing safe and effective medical services to clients. But sometimes these hospitals are the source of injury and death in patients by creating medical errors. In this systematic review study, the application of human factor analysis and classification system (HFACS) method in the classification of medical errors was investigated. Major electronic databases including Scopus, Web of Science, and MEDLINE were searched. All studies that investigated the application of HFACS method for coding, causation, and classification of medical errors and adverse events conducted from 2001 until February 2021 were included. A total of 108 articles were found. Due to duplication, 18 studies were removed from the review list. After reading the titles and abstracts, 50 of these publications were excluded because they had objectives different from this review. The remaining 40 publications were retrieved for further assessment. Of these, 28 publications were excluded because it did not meet the inclusion criteria. Finally, 12 articles remained for the final systematic review. We found that in 65% of the selected studies, preconditions for unsafe acts have been the major causal level of medical errors and adverse events. In the majority of the studies, communication and coordination, adverse mental states, physical environment, crew resource management, and technological environment have also been recognized as the most important causal categories in this study. As a result, to prevent medical errors and adverse events, the main focus should be on controlling the preconditions for unsafe acts including personnel factors, operator conditions, and environmental factors.

Medical errors are numerous in medical activities. Considering the sensitivity and importance of the medical group’s professions, the emergence of an apparently simple error can cause the death of an individual or even a group of individuals. The present study aims the evaluation and reduction of human error using a system human error reduction and prediction approach System Human Error Reduction and Prediction Approach (SHERPA) in the nurses of Baqiyatallah hospital’s chemotherapy ward in 2019.

A cross‑sectional study was conducted in the chemotherapy ward using the SHERPA technique. Then, the duties were determined in detail using Hierarchical Task Analysis (HTA). The errors were identified using the SHERPA checklist, and the risk outcomes and intensities were finally evaluated.

Based on the study findings, there are 109 possible errors for 48 sub‑duties. The most frequent errors fall in the functional area (54%) and the least frequent errors pertain to the area of selection (3%).

In order to reduce the errors and increase the quality of the services and safety of the patients, errors can be identified by using the SHERPA technique; after identifying these errors, using this technique, it is possible to prevent the recurrence of the identified errors by careful planning. Considering the fact that the most frequent error was found in the functional domain, modern protocols can be codified in this area, and standards can be observed for putting the problems of this section atop of the priority list and reducing the errors and increasing safety of the patients.

Medical errors are an important concern in medical practice and may occur throughout the processes of diagnosis, treatment, prevention, and rehabilitation. Despite the use of modern technology in health care, these errors remain one of the most challenging issues that medical management seeks to minimize.

Patient safety as a goal can be achieved by reporting medical errors (ME); however, most errors are never reported. The aim of this study is to explore the causes of ME, and the obstacles in reporting them amongst nurses.

We conducted semi‑structural interviews, with 12 nursing managers in the biggest teaching hospital in southern Iran (2015‑2016). The interview guide concentrated on the causes of ME and barriers in reporting them. All face‑to‑face interviews were recorded and transcribed verbatim and analysed using thematic analysis.

In this study 4 main themes were extracted for the causes of ME: personal/social characteristics, nonprofessional practice, hospital related factors/organization contextual factors, and poor management. Also, 5 main themes (such as; personal characteristics, fear from reporting, nonprofessional practices, cultural and social factors, and error surveillance system features) were obtained with regards to barriers in reporting.

ME can be reduced by improving professional practice and better human resource management. Also, reporting errors can be increased by focusing on cultural and social factors

Medication errors (MEs) are considered the most common medical errors and as one of the major challenges threatening the health system, which can be also reduced. MEs threaten patients' safety and may increase the length of hospital stay, lead to unexpected complications, mortality and side costs. In 2017, the World Health Organization launched Medication without Harm to reduce severe avoidable medication-related damage by 50%, globally in the next 5 years. Emergency Departments (EDs) are stressful care environments which making EDs more prone to MEs. Therefore, EDs need to be seriously considered to reduce MEs and increase patients' safety. In this regard, it is of great significance to know about the most common stage of error in pharmacotherapy, the most common type of medication error and the most common causes of MEs in the emergency department practice setting. in conclusion, the most common types of MEs in EDs include drug omission error, wrong dose and strong infusion rate. In addition, the administration and prescribing are the most common stages of MEs in EDs. Also, the most common causes of MEs in EDs in Iran include nursing shortage (fatigue) and poor medication knowledge .

Medical error is one of the most important causes of mortality and morbidity in the health care system. Considering the significance of medical error management in the healthcare system, error disclosure is an imperative moral responsibility of medical and healthcare professionals from medical ethics experts’ perspective. In literature, no or inadequate protocols were suggested for disclosing colleague’s medical error; and hence, this study was conducted to provide two algorithms for colleague’s medical error disclosure at individual and organizational levels.

This study conducted a narrative review on several valid Internet databases, including PubMed, Science Direct, and Scopus. First, the literature on the colleague’s error was reviewed using articles of the last 20 years focusing on medical errors and error disclosure keywords. Next, two algorithms were developed for the colleague’s error disclosure for individuals and with the assistance of organizations, respectively.

If we personally notice a colleaguechr('39')s error at an individual level, we should plan for a conversation to encourage the colleague to inform the patient or the related organization about the error. If we notice a medical error from a colleague relating to an organization, we should decide based on circumstances considering the organization’s responsible parties for handling error disclosure.

This  study  proposes a simple protocol for detecting peer error at the individual level and at the organizational level, using the existing literature. However, the improvement of these types of methods requires analysis of the specific conditions of each health system.

It is ensured that nurses’ error reporting and disclosing improve services to patients and are considered a movement toward creating a culture of transparency in the healthcare system.

This study aimed to investigate the nurses’ decisions on reporting and disclosing Medical Errors (MEs).

This research followed a mixed-method embedded design that was performed in five hospitals in Iran in 2018. A total of 491 nurses participated in the quantitative phase of the study with stratified sampling, followed by a simple random sampling technique. Also, 22 nurses joined the qualitative phase. Data were collected using a researcher-made questionnaire and semi-structured interviews through a scenario-based method. Quantitative data analysis was performed using descriptive and analytical statistics by SPSS 21.0 and Expert Choice 10.0 software. The qualitative data were analyzed based on the content analysis approach.

The most important perceived barriers with the highest impact coincided with educational (57.17%) and motivational (56.77%) factors based on SEM analysis (ES: 1.33, SE: 0.16). Regression analysis showed that error-reporting mechanisms, educational factors, and reporting consequences were significantly associated with age, sex, and work experience (P-Value ≤0.05). Error scenarios were thematized into three categories: Error perception (including ambiguity and weakness in error definition, the severity of the error, unawareness of guidelines, deviation from standards, and untrained staff), error reporting (including ineffective reporting system, hesitation in reporting to a formal system, increased workload, improper reaction, punitive responses, and concerns about consequences), and error disclosure (including no disclosure, partial disclosure, and full disclosure).

The obtained results contributed to a better understanding of the barriers to error reporting and disclosing. In addition, these results can help hospitals encourage error reporting and ultimately make organizational changes, which reduce the incidence of errors.

Nowadays, many countries all over the world are involved with COVID-19 and the number of new cases and deaths are on a rise. The role of emergency medicine and physician-led triage is important in this period. We report some near missed cases in our academic center related to this pandemic.

We report 5 cases that missed triage or received delayed diagnosis because of COVID-19 suspicion. Some cases are life threatening.

Although COVID-19 is the main health concern these days, other critical conditions should be considered. Stabilizing patients before transferring them between hospitals should be the essential goal of emergency department whether the patient is Corona virus infected or not. And before any intervention, the safety of healthcare workers must be ensured.

Medical errors have dramatic clinical and economic consequences. Using various information technology can reduce medical errors and improve services’ quality via preventing medical errors. In this study, the role of a computerized medical order entry system was investigated in reducing medical errors.

This study was conducted as a scoping review. The research question was formulated; then, the inclusion and exclusion criteria, keywords (such as medical errors, adverse event, physician order entry system and control) and search strategy were determined. International databases(Scopus, ProQuest, and PubMed) and manual searches were used. The studies that had the inclusion criteria were entered into the study and were evaluated qualitatively, then information of studies was extracted and summarized.

In total, 16 studies were included. Most studies were about medication errors and adverse medication events. So, it is possible to claim more confidently about reducing medication errors to adverse medication events, since in studies, the impact of this system on medication errors had been further discussed. Some studies have pointed to an increase in error reports due to better checking and error entry with this system, and in general, the positive impact of this action has been mentioned in minimizing errors, especially medication errors and adverse medication events. Positive and significant effects have also been reported on prescribing errors, especially medication prescriptions.

Computerization of medical orders through its positive effects, can be considered a useful and appropriate intervention in increasing patient safety if implemented completely and correctly.

N-Acetylcysteine (NAC) is a cost-effective antioxidant and very useful treatment for several diseases.

Here we report a rare case of iatrogenic NAC overdose following the mistake in calculation of the loading dose.

The patient was 14 years old girl referred to a local hospital due to history of intentional ingesting about 7grams acetaminophen. The physician prescribed her 6 grams NAC as a loading dose but 42grams NAC were infused by mistake. After infusion, the patient showed signs of anaphylactic shock and then transferred to Imam Reza toxicology-unite with weakness, lethargy, extreme fatigue, nausea, and dizziness. NAC overdosing, in a short period of time, led to coagulopathy, reduced platelet count, acute renal failure and metabolic acidosis. After 24 h, the patient died. The Medical forensic examination showed minor lung hemorrhage and presence of little amount of Aluminum phosphide in tissues they did not find no vital organ hemorrhage. It is unclear related to NAC overdose, phosphine intoxication or synergic effects.

Massive transfusion of NAC was associated with impairment of coagulation factors, intracranial hypertension, renal failure and metabolic acidosis. Thus, NAC administration should be with caution. The medical history of patients committed suicide are not always accurate and complete evaluation are recommended