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Communication Errors (communication + error)

Distribution by Scientific Domains
Medical Sciences75%

Selected Abstracts

Profiles in Patient Safety: Medication Errors in the Emergency Department

ACADEMIC EMERGENCY MEDICINE, Issue 3 2004
Pat Croskerry MD
Abstract Medication errors are frequent in the emergency department (ED). The unique operating characteristics of the ED may exacerbate their rate and severity. They are associated with variable clinical outcomes that range from inconsequential to death. Fifteen adult and pediatric cases are described here to illustrate a variety of errors. They may occur at any of the previously described five stages, from ordering a medication to its delivery. A sixth stage has been added to emphasize the final part of the medication administration process in the ED, drawing attention to considerations that should be made for patients being discharged home. The capability for dispensing medication, without surveillance by a pharmacist, provides an error-producing condition to which physicians and nurses should be especially vigilant. Except in very limited and defined situations, physicians should not administer medications. Adherence to defined roles would reduce the team communication errors that are a common theme in the cases described here. [source]

Design and implementation of Anycast communication model in IPv6

INTERNATIONAL JOURNAL OF NETWORK MANAGEMENT, Issue 3 2009
Xiaonan Wang
The existing designs for providing Anycast services are either to confine each Anycast group to a preconfigured topological region or to distribute members of Anycast groups over global regions. The former brings an Anycast scalability problem and the latter causes the routing tables to grow proportionally to the number of all global Anycast groups in the entire Internet. Therefore, both of the above designs restrict and hinder the application and development of Anycast services. A new kind of Anycast communication model is proposed in this paper which solves some existing problems, such as scalability and communication errors between clients and servers. In this paper, the Anycast communication model is analyzed in depth and discussed, and the experimental data of this Anycast communication model demonstrate its feasibility and validity. [source]

Unplanned anesthesia-related admissions to pediatric intensive care , a 6-year audit

PEDIATRIC ANESTHESIA, Issue 6 2007
IRINA KUROWSKI MBBS FANZCA
Summary Background:, Unplanned admissions to the intensive care unit may result from unexpected events related to anesthesia, and are recommended by some healthcare organizations as a clinical indicator. The rate of anesthesia-related unplanned admissions in adults ranges between 0.04% and 0.45% of procedures. However, there is a paucity of data relating to the rate in children. Methods:, Admissions to the pediatric intensive care unit (PICU) occurring within 24 h of anesthesia were identified through retrospective chart review. Only those admissions from a complication of anesthesia were included and not those from communication errors or surgical problems. The aim was to determine the rate of unplanned admissions, as well as the causes and management of this group of unplanned admissions. Results:, Seventy-six children requiring admission to the PICU were identified from 55196 procedures during the 6-year study period. The rate of unplanned admission was 0.14% of procedures. A total of 47% of these admissions were related to airway problems and 68% of children requiring admission were aged less than 5 years. Most children required only observation after their admission. Conclusions:, We found the unplanned admission rate to the PICU in our hospital population to be similar to that reported for adults, and is a relatively rare event in pediatric anesthesia. Most admissions were for children aged less than 5 years and were as a result of airway problems. Most cases were deemed potentially predictable. [source]

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities

PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 10 2010
Richard A. Hansen
Abstract Purpose To explore the use of disproportionality analysis of medication error data as a novel method to identify relationships that might not be obvious through traditional analyses. This approach can supplement descriptive data and target quality improvement efforts. Methods Data came from the Medication Error Quality Initiative (MEQI) individual event reporting system. Participants were North Carolina nursing homes who submitted incident reports to the Web-based MEQI data repository during the 2006 and 2007 reporting years. Data from 206 nursing homes were summarized descriptively and then disproportionality analysis was applied. Associations between medication type and possible causes at the state level were explored. A single nursing home was selected to illustrate how the method might inform quality improvement at the facility level. Disproportionality analysis of drug errors in this home was compared with benchmarking. Results Statewide, 59 drug-cause pairs met the disproportionality signal and 11 occurred in 10 or more reports. Among these, warfarin was co-reported with communication errors; esomeprazole, risperidone, and nitrofurantoin were disproportionately associated with transcription error; and oxycodone and morphine were disproportionately reported with name confusion. Facility-level analyses illustrate how descriptive frequencies and disproportionality analysis are complementary, but also identify different safety targets. Conclusions Exploratory analysis tools can help identify medication error types that occur at disproportionate rates. Candidate associations might be used to target patient safety work, although further evaluation is needed to determine the value of this information. Copyright © 2010 John Wiley & Sons, Ltd. [source]