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OBJECTIVE To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU). STUDY DESIGN A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified chi(2) test was used for analysis. RESULT 6749 NICU medication error(More)
Despite the growing demand for improved safety in health care, debate remains regarding the magnitude of the problem and the degree to which harm is preventable. To a great extent, this debate stems from variation in the definition and methods for measuring safety, its "shadow" error, and the degree of preventability. This article reviews the definition of(More)
Data from a 1983-88 retrospective panel study of 797 rural (non-Metropolitan Statistical Area) U.S. hospitals revealed that less than one in five (18.7%) had any alcohol and chemical abuse (ACA) service. About one-third of both inpatient and outpatient services had been established during the study period, but few hospitals not offering these services(More)
PURPOSE The aim of this study was to describe the design and lessons learned from implementing a large-scale patient safety collaborative and the impact of an intervention on teamwork climate in intensive care units (ICUs) across the state of Michigan. MATERIALS AND METHODS This study used a collaborative model for improvement involving researchers from(More)
Intensive care is one of the largest and most expensive components of American health care. Studies suggest that errors and resulting adverse events are common in intensive care units (ICUs). The incidence may be as high as 2 errors per patient per day; 1 in 5 ICU patients may sustain a serious adverse event, and virtually all are exposed to serious risk(More)
OBJECTIVE To determine whether high patient inflow volumes to an intensive care unit are associated with unplanned readmissions to the unit. DESIGN Retrospective comparative analysis. SETTING The setting is a large urban tertiary care academic medical center. PATIENTS Patients (n = 3233) discharged from an adult neurosciences critical care unit to a(More)
PURPOSE To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety. MATERIALS AND METHODS Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States(More)
The Institute of Medicine's (IOMs) report, "To Err is Human," recently addressed patient safety in the United States, alerting the nation to the need for improved systems of health care. Seven main findings were addressed in this report, we focus on 3: (1) patient safety is a nationwide problem, (2) health care workers are not to blame, and (3) safety and(More)
OBJECTIVE To analyze the system factors related to "line, tube, and drain" (LTD) incidents in the intensive care unit (ICU). DESIGN Voluntary, anonymous Web-based patient safety reporting system. SETTING Eighteen ICUs in the United States. PATIENTS Incidents reported by ICU staff members during a 12-month period ending June 2003. INTERVENTIONS None.(More)