Pennsylvania Physician Ebook Continuing Education

CONCLUSION

releases/diagnostic_errors_more_common_costly_ and_harmful_than_treatment_mistakes 16. Newman-Toker DE, Wang Z, Zhu Z, et al. Rate od diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections and cancers: toward a national incidence estimate using the “Big Three”. Diagnosis 2021;8:67-84. 17. National Academies of Medicine. Improving Diagnosis in Healthcare. Washington (DC): National Academies Press (US); 2015 Dec 29. https://www.ncbi.nlm.nih.gov/books/ NBK338596/ doi: 10.17226/21794 18. Agency for Healthcare Research and Quality (AHRQ). Systems approach. 2015a. March 8, 2022. https://psnet. ahrq.gov/primers/primer/21/systems-approach. 19. National Coordinating Council for Medication Error Reporting and Prevention. What is a medication error? 2022 Mar 8. https://www.nccmerp.org/about-medication- errors. 20. Food and Drug Administration (FDA). Working to reduce medication errors. nd. 2022 Mar 7. https://www.fda. gov/drugs/information-consumers-and-patients-drugs/ working-reduce-medication-errors. 21. Centers for Disease Control and Prevention (CDC) HAI data and statistics. 2018. March 8, 2022. https://www. cdc.gov/hai/surveillance/index.html. 22. Magill, S.S., Edwards, J.R., Stat, M., Bamberg, W., Zintars, G., Beldavs, M.S., et al. Multistate point-prevalence survey of healthcare-associated infections. N Engl J Med 2014;370, 1198–1208. doi: 10.1056/NEJMoa130680 23. Agency for Healthcare Research and Quality (AHRQ). Wrong-site, wrong-procedure, and wrong-patient surgery. 2019. March 8, 2022. https://psnet.ahrq.gov/primers/ primer/18/wrong-site-wrong-procedure-and-wrong- patient-surgery 24. Ross, M. What makes pharmacist mistakes more likely? 2015. 2022 Mar 8. http://www.pharmacytimes.com/news/ what-makes-pharmacist-mistakes-more-likely. 25. Rice, S. Most laboratory errors happen outside the lab, ECRI report finds. 2014. 2022 Mar 8. http:// www.modernhealthcare.com/article/20140417/ NEWS/304179961. 26. Singh G, Patel RH, Boster J. Root Cause Analysis and Medical Error Prevention. [Updated 2021 Nov 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK570638/. 27. Joint Commission. Sentinel event statistics released for 2020. 2021 Mar 24. https://www.jointcommission.org/ resources/news-and-multimedia/newsletters/newsletters/ joint-commission-online/march-24-2021/sentinel-event- statistics-released-for-2020/. 28. Wheeler, KK. Effective handoff communication. OR Nurse, 2014; 8(1), 22-26. doi: 10.1097/01. CCN.0000472849.85679.c4. 29. Gill S, Mills PD, Watts BV, et al. Review of adverse event reports from emergency department in the Veterans Health Administration. J Patient Saf. 2021;17:e898–e903. 30. Makary, Martin and Daniel, Michael. Analysis: Medical error—the third leading cause of death in the US. The British Medical Journal. BMJ 2016;353:i2139 doi: 10.1136/bmj.i2139 (Published 3 May 2016). 31. Yonash RA, Taylor MA. Wrong-side surgery in Pennsylvania during 2015-2019: a study of variables associated with 368 events from 178 facilities. Patient Safety. 2020;2:25- 39. 32. Centers for Medicare & Medicaid Services. Patient safety areas of focus. 2014. March 8, 2022. https:// partnershipforpatients.cms.gov/about-the-partnership/ what-is-the-partnership-about/lpwhat-the-partnership- is-about.html. 33. PSNet. Medication errors and adverse drug events. 2019 Sep 7. https://psnet.ahrq.gov/primer/medication-errors- and-adverse-drug-events. 34. Stoppler MC. The most common medication errors. 2018. 2022 Mar 8. http://www.medicinenet.com/script/main/art. asp?articlekey=55234. 35. Halli-Tierney AD, Scarbrough C, Carroll D. Polypharmacy: evaluating risk and deprescribing. Am Fam Physican. 2019:100:32-38. 36. Latif, A., Rawat, N., Pustavoitau, A., Ponovost, P. J. & Pham, J.C. National study on the distribution, causes,

and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. Crit Care Med, 2013;41 (2), 389-98. doi: 10.1097/ CCM.0b013e318274156a 37. Institute for Safe Medication Practices. (ISMP) ISMP list of high-alert medications in acute care settings. 2014. 2022 Mar 8. https://www.ismp.org/tools/highalertmedications. pdf. 38. Food and Drug Administration (FDA). Medication error reports. 2017. https://www.fda.gov/drugs/drugsafety/ medicationerrors/ucm080629.htm. 39. Beckers Hospital Review. 36 approaches to reducing 9 common medical errors. 2014. March 8, 2022. http:// www.beckershospitalreview.com/quality/36-approaches- to-reducing-9-common-medical-errors.html. 40. National Healthcare Safety Network. Central line- associated bloodstream infections. 2022 Mar 2. https:// arpsp.cdc.gov/profile/infections/clabsi?redirect=true. 41. Becker’s Clinical Leadership & Infection Control. Evidence- based approaches to hand hygiene: Best practices for collaboration. 2013. March 8, 2022. https://www. beckershospitalreview.com/quality/evidence-based- approaches-to-hand-hygiene-best-practices-for- collaboration.html. 42. Marschall, J., Mermel, L., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N., Yokoe, D. Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 2014;35(7), 753-771. doi:10.1086/676533 43. Siegel, M., & Kramer-Cain, J. Vascular catheter-associated infections. 2013. 2015 Nov 8. http://nursing.advanceweb. com/Article/Vascular-Catheter-Associated-Infections-2. aspx 44. Joint Commission. New sentinel event alert focuses on preventing falls. 2015b. March 8, 2022. https://www. jointcommission.org/assets/1/18/SEA_55.pdf 45. Centers for Disease Control and Prevention (CDC). Take a stand on falls. https://www.cdc.gov/features/older-adult- falls/index.html. 2017. March 8, 2022. 46. Kistler BM, Khubchandani J, Jakubowicz G, et al. Falls and Fall-Related Injuries Among US Adults Aged 65 or Older With Chronic Kidney Disease. Prev Chronic Dis. 2018;15:170518. 47. Padula WV, Delarmente BA. The national cost of hospital- acquired pressure injuries in the United States. Int Wound J. 2019;16:634–640. 48. Cooper KL. Evidence-based prevention of pressure ulcers in the intensive care unit. Critical Care Nurse. 2013;33(6), 57-67. doi: 10.4037/ccn2013985 49. Kirman CN. Pressure ulcers and wound care treatment & management. 2020. March 8, 2022. http://emedicine. medscape.com/article/190115-treatment#d16. 50. Centers for Disease Control and Prevention (CDC) Data and statistics on venous thromboembolism. 2020. 2022 Mar 8. Https://www.cdc.gov/ncbddd/dvt/data.html. 51. American Academy of Orthopedic Surgeons. Deep vein thrombosis. 2021. March 8, 2022. http://orthoinfo.aaos. org/topic.cfm?topic=a00219. 52. WebMD. How to prevent deep vein thrombosis (DVT). 2020. 2022 Mar 8. http://www.webmd.com/dvt/deep- vein-thrombosis-prevent-dvt?page=2 53. Cornell University Law School. Public health service act. 2022 Mar 8. https://www.law.cornell.edu/uscode/ text/42/chapter-6A. 54. Health US News. 50,000 fewer deaths caused by hospitals. 2014. 2022 Mar 8,. http://health. usnews.com/health-news/hospital-of-tomorrow/ articles/2014/12/02/fewer-americans-harmed-or- killed-by-hospital-errors 55. National Patient Safety Foundation. Free from harm. Accelerating patient safety improvement fifteen years after To Err is Human. 2015. 2022 Mar 8. http:// www.ihi.org/resources/Pages/Publications/Free-from- Harm-Accelerating-Patient-Safety-Improvement.aspx.

As summarized in this activity, medical errors remain a significant challenge for all aspects of the healthcare system and error rates are significantly higher in the United States compared with other developed countries. Root cause analysis reports are a useful tool to determine the primary systems- based factors of common medical errors. In the future, information technology, including electronic medical records, electronic prescribing, bar coding of medications, and decision support systems needs to be better, and more broadly, utilized in an effort to improve patient safety.

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