Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
1 - 20 of 23
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.
Craynon R, Hager DR, Reed M, et al. Am J Health Syst Pharm. 2018;75:1486-1492.
Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2015;29:340-6.
Clinical staff often fail to call rapid response teams to evaluate deteriorating patients, even when objective criteria for calling the team are met. This qualitative study of physicians and nurses at an Australian hospital found that an impaired culture of safety can result in failure to use the rapid response team when appropriate and can also lead to using the team as a workaround to compensate for poor interdisciplinary communication.
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Gao H, McDonnell A, Harrison DA, et al. Intensive Care Med. 2007;33:667-79.
Rapid response teams are being widely implemented in hospitals worldwide. These teams are summoned to evaluate patients who meet specific clinical "triggers" (e.g., abnormal vital signs). This systematic review evaluated the ability of such triggers to accurately identify inpatients whose clinical condition is deteriorating. The false-negative rate of commonly used triggers was relatively high, meaning that a significant proportion of acutely unstable patients would not be identified by such criteria. This problem was noted in a prior negative study of rapid response teams. The authors recommend further research to determine the combination of triggers that most accurately identifies clinical instability.
Jones D, Baldwin I, McIntyre T, et al. Qual Saf Health Care. 2006;15:427-32.
Medical emergency teams (METs, also known as rapid response teams) are being widely implemented in U.S. hospitals. Although their effectiveness in preventing adverse patient outcomes is uncertain, a major proposed benefit of such teams is to provide support for nursing staff. This study, conducted at an Australian hospital with a long-standing MET, surveyed ward nurses to determine if they understood the appropriate reasons to call the MET and evaluate if they felt the MET improved patient safety. Nearly all nurses felt the team helped provide more effective care for patients and helped educate nurses in caring for acutely ill patients. Nurses did not feel that they would be criticized for calling the MET. Despite the presence of objective criteria (eg, vital sign abnormalities) for calling the MET, most nurses preferred to use their clinical judgment to decide when to summon the team.
With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication.
A woman presents to the ED with severe vertigo and vomiting. Over several hours, she is handed off to three different physicians, none of whom suspects a dangerous lesion. Later, an hour after onset of a severe headache, she dies.