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ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.

Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.
First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused.
Greer JA, Haischer-Rollo G, Delorey D, et al. Cureus. 2019;11:e4096.
This pre–post study examined the effect of team training on an emergency response team's performance in a perinatal emergency simulation. Following the training, performance in the simulation identified more latent safety threats and adherence to a safety checklist increased. The authors suggest that team training can enhance maternal safety.
Grunebaum A, Chervenak F, Skupski D. Am J Obstet Gynecol. 2011;204:97-105.
Implementing a comprehensive safety program, which included teamwork training, additional staffing and reduction of work hours, electronic medical records, and a dedicated patient safety nurse, was associated with a sharp reduction in malpractice lawsuits and sentinel events at an academic hospital.
An unclear verbal order leads to administration of the wrong drug.