Evaluation of a Computer Application for Retrospective Detection of Vitamin K Antagonist Treatment Imbalance.

Abstract:

OBJECTIVE:Management of vitamin K antagonists (VKAs) is difficult, and overdoses can have dramatic hemorrhagic consequences. The adverse drug event (ADE) scorecards is a tool intended for the detection and description of adverse drug reaction/ADE developed during a European computerized medical data processing project. It is used in a quality assurance process. Our objective was to evaluate the performance of the ADE scorecards in the detection of the contributing factors for VKA overdoses, among the cases where a VKA overdose is observed. METHODS:Twenty-eight rules allow the detection of VKA treatment overdose related to drug or a clinical situation. They were applied on 14,748 electronic medical records from a community hospital. Among 582 records including a VKA prescription, 59 cases of VKA overdoses (international normalized ratio ≥ 5) during the hospital stay have been identified. The ADE scorecards detected 49 of them. We evaluated the positive predictive value and sensitivity of these rules, by an expert review of the cases. RESULTS:The expert review confirmed the contribution of a detected risk factor to the VKA overdose in 11 cases. Therefore, the precision of the rules is 22.4%. The sensitivity is 84.6%. The risk factors were mainly infection and amiodarone introduction. The 4 cases of clinical injury related to a drug were properly designated by the rules. CONCLUSIONS:Our study shows the great potential of the ADE scorecards for detecting cofactors of VKA overdoses and gives an argument to include complex rules in the knowledge bases used for the detection and identification of ADEs in large medical databases.

journal_name

J Patient Saf

authors

Ferret L,Luyckx M,Ficheur G,Chazard E,Beuscart R

doi

10.1097/PTS.0000000000000182

subject

Has Abstract

pub_date

2018-06-01 00:00:00

pages

115-123

issue

2

eissn

1549-8417

issn

1549-8425

journal_volume

14

pub_type

杂志文章
  • Influence of Gender, Profession, and Managerial Function on Clinicians' Perceptions of Patient Safety Culture: A Cross-National Cross-Sectional Study.

    abstract:OBJECTIVES:In recent years, several instruments for measuring patient safety culture (PSC) have been developed and implemented. Correct interpretation of survey findings is crucial for understanding PSC locally, for comparisons across settings or time, as well as for planning effective interventions. We aimed to evalua...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000585

    authors: Gambashidze N,Hammer A,Wagner A,Rieger MA,Brösterhaus M,Van Vegten A,Manser T,WorkSafeMed Consortium.

    更新日期:2019-03-15 00:00:00

  • Prevalence of Implanted Medical Devices in Medicine Inpatients.

    abstract::Implanted medical devices (IMDs) are extremely common, yet they are not systematically documented on hospital admission. Through structured patient interviews, we determined the prevalence of IMDs in hospital inpatients. Using medical record review, we evaluated the sensitivity of the medical record reporting of IMDs ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000187

    authors: Kuder M,Gelman A,Zenilman JM

    更新日期:2018-09-01 00:00:00

  • An NTSB for health care: learning from innovation: debate and innovate or capitulate.

    abstract:INTRODUCTION:Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable s...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3182446c51

    authors: Denham CR,Sullenberger CB 3rd,Quaid DW,Nance JJ

    更新日期:2012-03-01 00:00:00

  • Development of a Trigger Tool to Identify Adverse Drug Events in Elderly Patients With Multimorbidity.

    abstract:PURPOSE:Elderly patients with multimorbidity are especially vulnerable to adverse drug events (ADEs) and had high prevalence rates. Identifying ADEs is essential for enabling timely interventions that can mitigate the adverse events detected and for developing targeted strategies to prevent their occurrence as well as ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000389

    authors: Toscano Guzmán MD,Galván Banqueri M,Otero MJ,Alfaro Lara ER,Casajus Lagranja P,Santos Ramos B

    更新日期:2017-06-14 00:00:00

  • Patient Safety Activity Under the Social Insurance Medical Fee Schedule in Japan: An Overview of the 2010 Nationwide Survey.

    abstract:OBJECTIVES:Little is known about patient safety performance under the social insurance medical fee schedule in Japan. The Health Ministry in Japan introduced the preferential patient safety countermeasure fee (PPSCF) to promote patient safety in 2006 and revised the PPSCF system in 2010. This study aims to address the ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000432

    authors: Hirose M,Kawamura T,Igawa M,Imanaka Y

    更新日期:2017-11-16 00:00:00

  • Postoperative hemodynamic instability after simultaneous bilateral total knee arthroplasty.

    abstract:OBJECTIVES:After a simultaneously performed bilateral total knee arthroplasty, our institutional clinical experience suggested that there was an alarming incidence of severe postoperative hypotension and bradycardia. We therefore performed this study to define the incidence of postoperative hemodynamic instability and ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/pts.0b013e3181fe255d

    authors: Reidy CM,Beach ML,Gallagher JD,Sites BD

    更新日期:2010-12-01 00:00:00

  • Proactive Evaluation of an Operating Room Prototype: A Simulation-Based Modeling Approach.

    abstract:OBJECTIVES:There is a pressing need to improve safety and efficiency in the operating room (OR). Postsurgical adverse events, such as surgical site infections and surgical flow disruption, occur at a significant rate in industrial countries where a considerable portion of such complications result in death. The aim of ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000693

    authors: Taaffe K,Joseph A,Khoshkenar A,Machry H,Allison D,Reeves ST,RIPCHD.OR Study Group.

    更新日期:2020-03-13 00:00:00

  • Outpatient adverse drug events identified by screening electronic health records.

    abstract:OBJECTIVES:Relatively little is known about rates of outpatient adverse drug events (ADEs), and most health systems do not routinely identify them. We developed a computerized ADE measurement process and used it to detect ADEs from electronic health records and then categorized them according to type, preventability, a...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181dcae06

    authors: Gandhi TK,Seger AC,Overhage JM,Murray MD,Hope C,Fiskio J,Teal E,Bates DW

    更新日期:2010-06-01 00:00:00

  • Magnitude of Anemia at Discharge Increases 30-Day Hospital Readmissions.

    abstract:BACKGROUND:Anemia during hospitalization is associated with poor health outcomes. Does anemia at discharge place patients at risk for hospital readmission within 30 days of discharge? Our objectives were to examine the prevalence and magnitude of anemia at hospital discharge and determine whether anemia at discharge wa...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000138

    authors: Koch CG,Li L,Sun Z,Hixson ED,Tang A,Chagin K,Kattan M,Phillips SC,Blackstone EH,Henderson JM

    更新日期:2017-12-01 00:00:00

  • Hidden Barriers to Delivery of Pharmacological Venous Thromboembolism Prophylaxis: The Role of Nursing Beliefs and Practices.

    abstract:BACKGROUND:Standardized electronic order sets for venous thromboembolism prophylaxis have increased the proportion of patients receiving venous thromboembolism prophylaxis. However, ordering venous thromboembolism prophylaxis does not ensure consistent administration. OBJECTIVE:To explore causes of variability in the ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000086

    authors: Elder S,Hobson DB,Rand CS,Streiff MB,Haut ER,Efird LE,Kraus PS,Lehmann CU,Shermock KM

    更新日期:2016-06-01 00:00:00

  • Evaluation of a Program for Improving Advanced Imaging Interpretation.

    abstract:OBJECTIVES:Self-referred imaging has grown rapidly, raising concerns about increased costs and compromised quality of care. A quality improvement program using imaging interpretation criteria was designed by a national payer to ensure that noninvasive diagnostic images are interpreted by appropriately trained physician...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000345

    authors: Powell AC,Long JW,Kren EM,Gupta AK,Levin DC

    更新日期:2019-03-01 00:00:00

  • Nurses' Views Highlight a Need for the Systematic Development of Patient Safety Culture in Forensic Psychiatry Nursing.

    abstract:BACKGROUND:Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing. OBJECTIVES:The aim of this qualitative study was to describe nurses' views of...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000314

    authors: Kuosmanen A,Tiihonen J,Repo-Tiihonen E,Eronen M,Turunen H

    更新日期:2017-11-04 00:00:00

  • Psychometric Analysis of a Survey on Patient Safety Culture-Based Tool for Emergency Medical Services.

    abstract:OBJECTIVE:Evaluating organizational safety culture is critical for high-stress, high-risk professions such as prehospital emergency medical services (EMS). The aim of the study was to evaluate the psychometric properties of a safety culture instrument for EMS, based on the Agency for Healthcare Research and Quality's w...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000504

    authors: Crowe RP,Cash RE,Christgen A,Hilmas T,Varner L,Vogelsmeier A,Gilmore WS,Panchal AR

    更新日期:2018-06-11 00:00:00

  • System-Level Patient Safety Practices That Aim to Reduce Medication Errors Associated With Infusion Pumps: An Evidence Review.

    abstract:OBJECTIVES:In this literature review, we discuss 2 system-level, nurse-targeted patient safety practices (PSPs) that aim to reduce medication errors associated with infusion pumps, including smart pumps. One practice focuses on implementing structured process changes and redesigning workflows to improve efficiencies wi...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000722

    authors: Bacon O,Hoffman L

    更新日期:2020-09-01 00:00:00

  • The role of advice in medication administration errors in the pediatric ambulatory setting.

    abstract:BACKGROUND:In the pediatric setting, adverse events occurring at the administration stage are the most common type of preventable adverse drug events. Few data are available on the effect of advice from medical professionals on medication safety. METHODS:This is a prospective cohort study of 1685 pediatric patients, 6...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3181b3a9b0

    authors: Lemer C,Bates DW,Yoon C,Keohane C,Fitzmaurice G,Kaushal R

    更新日期:2009-09-01 00:00:00

  • Acute Fracture Neck of Femur Among Inpatients: Severe Injuries Which Need to be Taken Seriously.

    abstract:OBJECTIVES:This study assesses fall prevention measures and subsequent incident reporting of falls resulting in an "inpatient fracture neck of femur (FNOF)" within a single NHS Trust, with the aim of identifying potential areas of improvement and changing practice within a Trust. METHODS:Forty patients (mean age, 82.6...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000193

    authors: Green CM,Zeiton M,Foulkes K,Barrie J

    更新日期:2018-12-01 00:00:00

  • A Systematic Review of Methods for Medical Record Analysis to Detect Adverse Events in Hospitalized Patients.

    abstract:OBJECTIVE:In this systematic review, we evaluate 2 of the most used trigger tools according to the criteria of the World Health Organization for evaluating methods. METHODS:We searched Embase, PubMed, and Cochrane databases for studies (2000-2017). Studies were included if medical record review (MRR) was performed wit...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000670

    authors: Klein DO,Rennenberg RJMW,Koopmans RP,Prins MH

    更新日期:2020-03-11 00:00:00

  • Merits of using color and shape differentiation to improve the speed and accuracy of drug strength identification on over-the-counter medicines by laypeople.

    abstract:OBJECTIVE:This study aimed to examine the utility of using color and shape to differentiate drug strength information on over-the-counter medicine packages. Medication errors are an important threat to patient safety, and confusions between drug strengths are a significant source of medication error. METHOD:A visual s...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/pts.0b013e3181eee157

    authors: Hellier E,Tucker M,Kenny N,Rowntree A,Edworthy J

    更新日期:2010-09-01 00:00:00

  • UDI2Claims: Planning a Pilot Project to Transmit Identifiers for Implanted Devices to the Insurance Claim.

    abstract:BACKGROUND:In response to problems with the current postmarket surveillance of medical devices, the U.S. Food and Drug Administration mandated device labelers to include a unique device identifier (UDI), composed of a device identifier (DI) and production identifier. Including the DI in insurance claims could be a pote...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000543

    authors: Zerhouni YA,Krupka DC,Graham J,Landman A,Li A,Bhatt DL,Nguyen LL,Capatch K,Concheri K,Reich AJ,Wilson N,Weissman JS

    更新日期:2018-11-21 00:00:00

  • Perception Gaps of Disclosure of Patient Safety Incidents Between Nurses and the General Public in Korea.

    abstract:OBJECTIVES:This study aimed to explore nurses' perceptions regarding disclosure of patient safety incidents. METHODS:An anonymous online survey was conducted, and results were compared with those of the general public using the same questionnaire in a previous study. RESULTS:Among 689 nurses, 96.8% of nurses felt maj...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000781

    authors: Choi EY,Pyo J,Lee W,Jang SG,Park YK,Ock M,Lee H

    更新日期:2020-09-08 00:00:00

  • Establishing the Foundation to Support Health System Quality Improvement: Using a Hand Hygiene Initiative to Define the Process.

    abstract:OBJECTIVES:As hospitals are increasingly consolidating into larger health systems, they are becoming better positioned to have far reaching and material impacts on safety and quality of care. When the Mount Sinai Health System (MSHS) was formed in 2013, it sought to ensure the delivery of safe, high-quality care to eve...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000578

    authors: Anderson R,Rosenberg A,Garg S,Nahass J,Nenos A,Egorova N,Rowland J,Mari J,LoPachin V

    更新日期:2021-01-01 00:00:00

  • The Patient Perspective on Errors in Cancer Care: Results of a Cross-Sectional Survey.

    abstract:OBJECTIVE:The objective of this study was to explore medical oncology outpatients' perceived experiences of errors in their cancer care. METHODS:A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centers. Partic...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000368

    authors: Carey M,Boyes AW,Bryant J,Turon H,Clinton-McHarg T,Sanson-Fisher R

    更新日期:2019-12-01 00:00:00

  • Adverse Event Reporting: Harnessing Residents to Improve Patient Safety.

    abstract:OBJECTIVES:Reporting of adverse and near miss events are essential to identify system level targets to improve patient safety. Resident physicians historically report few events despite their role as front-line patient care providers. We sought to evaluate barriers to adverse event reporting in an effort to improve rep...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000333

    authors: Tevis SE,Schmocker RK,Wetterneck TB

    更新日期:2020-12-01 00:00:00

  • The effect of hospital organizational characteristics on postoperative complications.

    abstract:OBJECTIVES:To determine if there is a relationship between the risk of postoperative complications and the nonclinical hospital characteristics of bed size, ownership structure, relative urbanicity, regional location, teaching status, and area income status. METHODS:This study involved a secondary analysis of 2006 adm...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0b013e3182995e5b

    authors: Knight M

    更新日期:2013-12-01 00:00:00

  • Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial.

    abstract:OBJECTIVES:Adverse drug events (ADEs) are common in ambulatory care and may result from poor patient-physician communication about medication-related symptoms. A module was developed within an electronic patient portal that was designed to enhance communication about medication symptoms and, in turn, reduce ADEs and he...

    journal_title:Journal of patient safety

    pub_type: 杂志文章,随机对照试验

    doi:10.1097/PTS.0b013e31829e4b95

    authors: Weingart SN,Carbo A,Tess A,Chiappetta L,Tutkus S,Morway L,Toth M,Davis RB,Phillips RS,Bates DW

    更新日期:2013-09-01 00:00:00

  • A Study on the Status and Contributory Factors of Adverse Events Due to Negligence in Nursing Care.

    abstract:BACKGROUND:Patient safety issues in medical institutions have received worldwide attention. Nurses play a pivotal role in providing health care at the bedside and the interception of adverse events (AEs). A knowledge of contributory factors for these AEs is vital to individuals, institutional procedures, and also natio...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000791

    authors: Kim MJ,Jang SG,Kim IS,Lee W

    更新日期:2020-10-01 00:00:00

  • A multicenter trial of aviation-style training for surgical teams.

    abstract:AIMS:This study measured the effect of aviation-style team training on 3 surgical teams from different specialties. It focused on team working and communication, particularly briefing, time-out, and debriefing, and sought to understand how improvements in team skills could be implemented in a broad range of naturalisti...

    journal_title:Journal of patient safety

    pub_type: 杂志文章,多中心研究

    doi:10.1097/PTS.0b013e3181f100ea

    authors: Catchpole KR,Dale TJ,Hirst DG,Smith JP,Giddings TA

    更新日期:2010-09-01 00:00:00

  • "Disbelief and Sadness": First-Year Health Profession Students' Perspectives on Medical Errors.

    abstract:OBJECTIVES:The aims of the study were to examine the reactions of first-year health profession students to medical errors and determine whether differences exist between disciplines. METHODS:After viewing the Team STEPPS Program's Susan Sheridan video that describes two separate medical errors, students from anesthesi...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000691

    authors: Davis BP,Clevenger C,Dillard R,Moulia D,Ander DS

    更新日期:2020-03-11 00:00:00

  • Community pharmacists' attitudes, perceptions, and barriers toward adverse drug reaction reporting in Malaysia: a quantitative insight.

    abstract:OBJECTIVES:This study was designed to explore awareness and attitudes of community pharmacists toward the national ADR reporting system activities in the northern states of Malaysia. METHODS:A cross-sectional survey using a validated self-administered questionnaire was used in this study. The questionnaire was deliver...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000051

    authors: Elkalmi RM,Hassali MA,Ibrahim MI,Jamshed SQ,Al-Lela OQ

    更新日期:2014-06-01 00:00:00

  • A Systematic Review of Patient-Report Safety Climate Measures in Health Care.

    abstract:OBJECTIVES:Patients are a valuable, yet underutilized source of information for safety measurement and improvement in health care. The aim of this review was to identify patient-report safety climate (SC) measures described in the literature, analyze the included items to consider their alignment with previously establ...

    journal_title:Journal of patient safety

    pub_type: 杂志文章

    doi:10.1097/PTS.0000000000000705

    authors: Madden C,Lydon S,O'Dowd E,Murphy AW,O'Connor P

    更新日期:2020-04-27 00:00:00