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Of the 3,197 sentinel events JCAHO has reviewed from January 1995 through June 30, 2005, almost 11%, or 326 incidents, involved a medication error, making it the fourth most common type of sentinel event reported.

More than one out of 10 sentinel events are drug errors

Of the 3,197 sentinel events JCAHO has reviewed from January 1995 through June 30, 2005, almost 11%, or 326 incidents, involved a medication error, making it the fourth most common type of sentinel event reported. Poor communication is the No. 1 root cause of these medication errors, followed by inadequate staff orientation and training. While the total number of medication errors dropped in 2004 as compared with 2003, those involving potassium chloride rose during the same period. These are some updated data JCAHO released recently on sentinel events, which are defined as an unexpected death or serious injury to the patient.

Chill out

I'm sorry, so sorry

Do hospitals that take the initiative to apologize to patients for committing a medical blooper get sued to a lesser extent than those that don't? Apparently an increasing number of hospitals believe this to be the case. For instance, hospitals in Illinois have implemented a program called "Sorry Works!" to teach health professionals how to 'fess up. Now a bill has been introduced in Congress, modeled after this program, to help hospitals own up to their errors and negotiate with patients who have been hurt by such incidents. The bill was introduced by Sens. Hillary Clinton (D, N.Y.) and Barack Obama (D, Ill.). Proponents believe that measures such as these lower hospitals' medical malpractice tabs.

AHRQ issues new evidence report on diabetes

The Agency for Healthcare Research & Quality (AHRQ) has come out with an evidence report on the diagnosis, prognosis, and treatment of impaired glucose tolerance (IGT) and impaired fasting glucose (IGT). Among its goals, the report sought to determine how effectively drugs could delay the onset of diabetes mellitus (DM) in patients with IGT and reduce the risk for cardiovascular events and stroke. Combing through studies published after 1978, the report found, among other things, that acarbose (Precose, Bayer) is associated with a reduced risk of progressing to DM as well as developing a major cardiovascular event. For additional findings on the value of other pharmacotherapeutic interventions, click on http://www.ahrq.gov/clinic/epcsums/impglusum.htm. Meanwhile, in a notice published in the Sept. 21 Federal Register, AHRQ said it is seeking nominations of topics for new evidence reports. Nominations should be submitted by Dec. 1 and should be e-mailed to epc@ahrq.gov

New tool kit helps eliminate abbreviations

Is your hospital having a hard time getting rid of dangerous medical abbreviations? If so, this new toolkit from Joint Commission Resources could come in handy. The Spell It Out! kit consists of items that remind doctors and other health professionals not to use certain abbreviations. Included are two clipboards, 10 laminated posters, 10 pocket-sized quick reference cards, 10 sticker sheets, and five multi-click pens with a window that displays all the do-not-use abbreviations. The tool kit costs $49.

VA hospitals choose MedRunner

Five Veterans Affairs hospitals have selected Bio-Optronics' Dynamic Hospital MedRunner as a contingency solution for BCMA (bar-coded medication administration), the VA's internal medication administration system. According to the Rochester, N.Y., firm, MedRunner can be integrated with the VA's BCMA or work as a stand-alone solution for medication administration. The five hospitals are in Martinsburg, W.V., the greater Baltimore area, and Washington, D.C.

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