Anatomy of an incident disclosure: the importance of dialogue.

BACKGROUND: Disclosure of health care incidents to patients and family members, as an ethical imperative, is becoming increasingly prevalent. The experiences of a woman whose husband died forms the basis for a case study of how she and her family and friends were able to renegotiate clinicians' understandings of what had gone wrong and influence their views of what needed to be done in response. METHODS: The case was constructed in late 2010 using the replicated single-case approach, which involved repeated checking and correcting details of an interview with the patient's wife. Her husband, diagnosed with multiple myeloma in 2006, was hospitalized in January 2009 following a hip replacement. While in the hospital, he received a vasopressin overdose. He died in February 2009. THE DISCLOSURE PROCESS: The basis of the disclosure was the drug error, yet the patient's wife informed the caller (the head of the ICU), "You've got a greater problem than a drug error... you've got a massive, big communication problem here." The disclosure process, which unfolded in a series of phone calls and meetings, enabled the patient's wife and her family not only to ask questions but to put forward their knowledge, views, and concerns, and it moved from "disclosing an incident" (the vasopressin overdose) to addressing repeated communication failures and inappropriate behaviors. As a result, the disclosure process became a genuine dialogue that informed the clinicians as much as the family. CONCLUSIONS: This case study expands our understanding of what is possible as part of disclosure communication. Patients and family members can and should play a critical role in quality improvement and patient safety, given their knowledge and questions about the trajectory of care and their passion for ensuring that similar incidents do not recur to harm others.

The prosecution of RaDonda Vaught: An ethical and legal mistake.

This paper addresses the ethics of the prosecution of nurse RaDonda Vaught for a medication error that led to the death of her patient. It is argued that the prosecution of Ms. Vaught was wrong; however, in contrast to some commentators, it is argued that the wrongness of Ms. Vaught's prosecution did not stem from its effects on patient safety, but from the fact that the charges, in this case, were legally and ethically unjustified in themselves.

Dealing honestly with an honest mistake.

A 70-year-old woman was admitted for a symptomatic left iliofemoral deep vein thrombosis. She underwent percutaneous mechanical thrombectomy, followed by overnight thrombolysis. The next day her clot had resolved, and a culprit left iliac vein stenosis was identified. After stent placement, a heparin infusion was initiated and the patient was taken back to the ward. At 11 the evening after the procedure, the resident on call was contacted to verify the written order. The resident stated that the heparin dose was to be 250 U/h; however, the nurse documented 2500 U/h and changed the infusion pump at the patient's bedside. At 5:30 the next morning, the resident was notified that the patient's partial thromboplastin time was >300 seconds and promptly shut off the heparin infusion. No noticeable adverse events occurred because of the high heparin dosing. The charge nurse was notified, as was risk management. What should the patient be told?

[Survey in hospitals. Nursing errors, error culture and error management]. / Befragung in Krankenhäusern. Pflegefehler, Fehlerkultur und Fehlermanagement.

Knowledge on errors is important to design safe nursing practice and its framework. This article presents results of a survey on this topic, including data of a representative sample of 724 nurses from 30 German hospitals. Participants predominantly remembered medication errors. Structural and organizational factors were rated as most important causes of errors. Reporting rates were considered low; this was explained by organizational barriers. Nurses in large part expressed having suffered from mental problems after error events. Nurses' perception focussing on medication errors seems to be influenced by current discussions which are mainly medication-related. This priority should be revised. Hospitals' risk management should concentrate on organizational deficits and positive error cultures. Decision makers are requested to tackle structural problems such as staff shortage.

Development of a Medication Safety and Quality Survey for Small Rural Hospitals.

PURPOSE: We summarize the development and initial implementation of a survey tool to assess medication safety in small rural hospitals. SUMMARY: As part of an ongoing rural hospital medication safety improvement program, we developed a survey tool in all 13 critical access hospitals (CAHs) in Florida. The survey was compiled from existing medication safety assessments and standards, clinical practice guidelines, and published literature. Survey items were selected based on considerations regarding practicality and relevance to the CAH setting.The final survey instrument included 134 items representing 17 medication safety domains. Overall hospital scores ranged from 41% to 95%, with a median of 59%. Most hospitals showed large variation in scores across domains, with 5 hospitals having at least 1 domain with scores less than 10%. Highest scores across all facilities were seen for safety procedures concerning high-alert or look-alike medications and the assembly of emergency carts. The lowest median scores included availability and consistent use of standardized order sets and the effective implementation of medication safety committees. Most hospitals used the survey results to identify and prioritize quality improvement activities. CONCLUSIONS: The survey can be used to conduct a short medication safety assessment specific to a limited number of areas and services in CAHs. It showed good ability to discriminate medication safety levels across participating sites and highlighted opportunities for improvement. It may need modification if case mix or services differ in other states or if the status quo of medication safety in CAHs or related standards advance. The described process of survey development might be helpful to support such modifications.

A qualitative analysis of student-written law and ethics cases: A snapshot of PY2 student experience.

INTRODUCTION: This study was designed to better understand pharmacy students' experiences and recognition of legal and ethical tensions existing in pharmacy practice as demonstrated in student-written law and ethics cases. METHODS: A qualitative analysis of 132 student-written cases representing the team efforts of 1053 students over a 12-year time period was conducted. Student-written cases were coded and analyzed thematically. RESULTS: Our results demonstrate the types of ethical and legal issues our students have experienced in pharmacy practice during the first five quarters of their professional education. Our data highlight three themes: 1) ethical dilemmas presented when the law is misapplied; 2) ethical dilemmas presented when an institutional policy or law was viewed as insufficient; and 3) ethical dilemmas presented as provider distress. The third theme was further subdivided into five subthemes. CONCLUSION: The themes that emerged from this study represent some of the ethical dilemmas that second professional year students have encountered and how these dilemmas may intersect with legal boundaries. Educators can use cases demonstrating these themes to reinforce law and ethics education in the curriculum, thus helping prepare students for pharmacy practice. This article recommends how and when to use case examples.

Medication Errors in the Southeast Asian Countries: A Systematic Review.

BACKGROUND: Medication error (ME) is a worldwide issue, but most studies on ME have been undertaken in developed countries and very little is known about ME in Southeast Asian countries. This study aimed systematically to identify and review research done on ME in Southeast Asian countries in order to identify common types of ME and estimate its prevalence in this region. METHODS: The literature relating to MEs in Southeast Asian countries was systematically reviewed in December 2014 by using; Embase, Medline, Pubmed, ProQuest Central and the CINAHL. Inclusion criteria were studies (in any languages) that investigated the incidence and the contributing factors of ME in patients of all ages. RESULTS: The 17 included studies reported data from six of the eleven Southeast Asian countries: five studies in Singapore, four in Malaysia, three in Thailand, three in Vietnam, one in the Philippines and one in Indonesia. There was no data on MEs in Brunei, Laos, Cambodia, Myanmar and Timor. Of the seventeen included studies, eleven measured administration errors, four focused on prescribing errors, three were done on preparation errors, three on dispensing errors and two on transcribing errors. There was only one study of reconciliation error. Three studies were interventional. DISCUSSION: The most frequently reported types of administration error were incorrect time, omission error and incorrect dose. Staff shortages, and hence heavy workload for nurses, doctor/nurse distraction, and misinterpretation of the prescription/medication chart, were identified as contributing factors of ME. There is a serious lack of studies on this topic in this region which needs to be addressed if the issue of ME is to be fully understood and addressed.

Medical errors and the trainee: ethical concerns.

How medical errors are handled by individual physicians and hospital systems is a topic of considerable interest. In teaching hospitals, medical students and house officers often observe and commit mistakes. Commission of a mistake is associated with serious emotional turmoil and uncertainty among trainees as well as experienced physicians. Although disclosure is the ethical standard, the consequences of disclosure are feared by many. This article focuses on the issues that surround medical errors as they pertain to medical students and residents. It is important that this group of future physicians has appropriate training, mentoring, and support when dealing with errors.

Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.

Thousands of medical errors are occurring daily in physician's offices, in hospitals, and even upon discharge from the hospital, leading to unnecessary injury and death and costing billions of dollars. We have a systems approach that has been proven to be tried and true in aviation, nuclear energy and many other industrial settings. Being honest when medical mistakes occur, reporting them to national clearing house, objectively searching for root causes, avoiding the fixing of arbitrary blame, and then, where possible, implementing safeguards to minimize the occurrence of future mistakes, is the best way to enhance patient safety. But until the medical establishment takes medical errors and patient safety more seriously, and until the general public rises up in protest, it is up to the state and federal governments to take the lead in protecting the lives of innocent Americans by creating a public policy.

Nuevas perspectivas en la resolución del error médico: National Health Service Resolution y CARe / New perspectives in resolving medical error: National Health Service Resolution and CARe

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Cuidados na administração de medicamentos: as responsabilidades dos profissionais de enfermagem / Care in the administration of medicines: the responsibilities of nursing professionals

Objetivo: avaliar o conhecimento de profissionais de enfermagem atuantes em uma instituição hospitalar pública quanto às responsabilidades jurídicas e éticas envolvidas na administração de medicamentos. Método: estudo avaliativo, exploratório, com abordagem quantitativa e qualitativa. Foram aplicados questionários a162 profissionais de enfermagem. Os dados quantitativos formaram um banco de dados, digitados no software Statistical Package for the Social Sciences – SPSS. As informações qualitativas foram submetidas à análise de conteúdo. Resultados: constatou-se que os profissionais de enfermagem necessitam de maior aprofundamento científico acerca do Código de Ética da Profissão e que o conhecimento dos enfermeiros acerca das responsabilidades perante os erros de medicação foi superior ao dos técnicos e auxiliares de enfermagem. A advertência verbal foi a principal conduta adotada para responsabilizar os profissionais envolvidos após a ocorrência dos erros. Conclusão: constata-se que o conhecimento acerca do direito e da deontologia propiciam um fazer com resultados efetivos.

Efecto sobre la salud de un grupo de pacientes crónicos polimedicados en una farmacia comunitaria / Effects of the pharmacotherapeutical follow-up in a community pharmacy on aged patients with multiple medications

Introducción: El seguimiento farmacoterapéutico (SFT) puede suponer importantes beneficios para la salud de los pacientes mayores polimedicados. Objetivos: Valorar la influencia de la implantación del SFT en la salud de nuestros pacientes. Evaluar la efectividad de las intervenciones farmacéuticas (IF). Analizar los resultados negativos asociados a la medicación (RNM) en función del principio activo y problema de salud. Método: Estudio longitudinal, descriptivo y no aleatorizado en mayores de 65 años polimedicados, siguiendo la metodología delprograma ConSIGUE. Los datos, correspondientes a diez pacientes, se recopilaron de estados de situación (ES), cuestionarios de utilización de recursos sanitarios, encuestas de calidad de vida y registros de RNM e IF. Resultados: Hubo reducción apreciable en número de principios activos, problemas de salud (PS), RNM y visitas a urgencias. Se registró un incremento de la percepción subjetiva de la calidad de vida. En la revisión, se retiró algún medicamento al 80% de los pacientes. Registramos 69 IF, siendo aceptadas 61 (~90%). Detectamos 28 RNM: 20 fueron resueltos (70%) y 2 son todavía objeto de seguimiento. Omeprazol, ácido acetilsalicílico y acenocumarol, estuvieron implicados en el 30% de los RNM. La prevención de gastrolesión, junto con patologías como diabetes y anticoagulación, se asociaron con el 60% de los RNM. Conclusiones: La inclusión en el SFT ha supuesto importantes beneficios en salud para nuestros pacientes. El uso extensivo de fármacos considerados seguros puede contribuir a la aparición de RNM en pacientes crónicos y polimedicados

Introduction: The implementation of a pharmacotherapeutical follow-up program can suppose many health benefits for aged patients with multiple medications. Objectives: The main objectives are to evaluate the impact of this program on patients’ health and the effectiveness of the pharmaceutical interventions. On the other hand, to analyze the negative results associated with the medication according to the active ingredient or the health problem involved. Methods: It was carried out a longitudinal, descriptive and non randomized study in aged patients with multiple medications, following ConSIGUE methodology. Data, concerning ten patients, were collected from assessment forms, use questionnaires of healthcare resources, quality of life surveys and negative results associated with medication and pharmaceutical interventions records. Results: There was a reduction in the number of active ingredients, health problems and hospitalization and emergency room visits. In contrast, an increase in the patients’ quality of life was found. At least, one medicine (outdated medicines or non active prescriptions) was withdrawn in 80% of the patients during the medication review. We recorded 69 pharmaceutical interventions from which 61 were accepted. 20 out of 28 negative results associated with medication were solved while 2 are still under study. Omeprazole, acetylsalicylic acid and acenocumarol were found to be responsible for 30% of negative results associated with medication. 60% of the negative outcomes recorded were associated to the prevention of ulcers and pathologies such as diabetes and anticoagulation. Conclusions: The inclusion in a pharmacotherapeutical follow-up program resulted in improved health outcomes of our patients. The extensive use of safe drugs may contribute to negative phamacotherapeutical results in aged patients with multiple medications

Els errors en les relacions assistencials: una aproximació des de la bioética / No disponible

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