Administering and monitoring high-alert medications in acute care. | PSNet

Provide Feedback |

Submit a Case

Register

Commentary

Administering and monitoring high-alert medications in acute care.

August 9, 2017

Cajanding JMR. Nurs Stand. 2017;31(47):42-52.

View more articles from the same authors.

High-alert medications are a recognized focus of efforts to improve medication safety. This commentary discusses nursing practice associated with high-alert medications and reviews tactics to help ensure these drugs are administered safely, such as the use of Tall Man lettering, independent double checks, and computerized provider order entry.

PubMed citation

Related Resources From the Same Author(s)

Cognitive biases associated with medical decisions: a systematic review.

February 1, 2017

Hospital surveys by the Centers for Medicare and Medicaid Services: an analysis of more than 34,000 deficiencies.

June 2, 2021

Speaking the same language. AHRQ seeks common method of safety reporting.

August 31, 2005

Making patient safety event data actionable: understanding patient safety analyst needs.

October 4, 2017

Medical error reduction and tort reform through private contractually-based quality medicine societies.

March 17, 2010

A piece of my mind. From shame to guilt to love.

January 6, 2016

Tracking intraoperative complications.

November 28, 2012

Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment Service?

June 13, 2012

Balancing patient safety, clinical efficacy, and cybersecurity with clinician partners.

April 28, 2021

For 4 days, the hospital thought he had just pneumonia. It was coronavirus.

March 25, 2020

The architecture of safety: hospital design.

November 28, 2007

A new frontier in patient safety.

June 1, 2011

Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety.

March 21, 2012

Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors.

April 3, 2019

The ethical imperative to think about thinking.

August 6, 2014

Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life.

May 10, 2006

Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.

November 1, 2006

Improving patient safety using interactive, evidence-based decision support tools.

December 14, 2005

Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.

August 17, 2011

Apology and unintended harm in global health.

July 17, 2019

Diagnosing crime and diagnosing disease—part 1 and part 2.

February 28, 2018

The architecture of safety: an emerging priority for improving patient safety.

November 21, 2018

Blinding or information control in diagnosis: could it reduce errors in clinical decision-making?

December 5, 2018

The hard talk: dealing with the disruptive physician.

January 20, 2021

Are apologies a way to reduce malpractice risks?.

June 21, 2023

Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

October 18, 2023

Patient Safety in the Traditional and Evolving Nontraditional Office Setting

October 2, 2019

Cost of health care-associated infections in the United States.

March 23, 2022

Embedding quality improvement and patient safety - the UCLA value analysis experience.

April 18, 2007

Teaching medical students about medical errors and patient safety: evaluation of a required curriculum.

June 15, 2005

The human factors of home health care: a conceptual model for examining safety and quality concerns.

December 9, 2009

Interruptions and medication administration in critical care.

July 29, 2015

Analyzing communication errors in an air medical transport service.

May 29, 2013

"It is the left eye, right?"

June 11, 2014

AI for radiographic COVID-19 detection selects shortcuts over signal.

June 16, 2021

Changes in hospital adverse events and patient outcomes associated with private equity acquisition.

January 10, 2024

Miles to go: an introduction to the 5 Million Lives Campaign.

August 8, 2007

Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit.

May 30, 2007

Effect of barcode-assisted medication administration on emergency department medication errors.

October 2, 2013

Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents.

December 7, 2016

The scope of drug-related problems in the home care setting.

July 25, 2018

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

February 3, 2016

Use of nondisclosure agreements in medical malpractice settlements by a large academic health care system.

May 27, 2015

Enhanced morbidity and mortality meeting and patient safety education for specialty trainees.

August 12, 2015

Safety, performance, and satisfaction outcomes in the operating room: a literature review.

July 11, 2018

Patterns of disrespectful physician behavior at an academic medical center: implications for training, prevention, and remediation.

December 12, 2018

Burnout syndrome among healthcare professionals.

December 13, 2017

Who is responsible for the safe introduction of new surgical technology? An important legal precedent from the da Vinci Surgical System Trials.

May 10, 2017

A perfect storm averted: flawed systems, a dropped ball, and cognitive biases delay a critical diagnosis.

November 2, 2022

Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk.

November 11, 2020

The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients.

March 24, 2021

An analysis of medical malpractice claims against medical oncologists from a national database: implications for safer practice.

January 10, 2024

Clinical reasoning as a core competency.

October 30, 2019

Association between operative autonomy of surgical residents and patient outcomes.

March 23, 2022

Medication administration process assessment: applying lessons learned from commercial aviation.

March 11, 2009

Reporting near-miss events in nursing homes.

April 19, 2006

Incivility in healthcare: the impact of poor communication.

August 2, 2023

Digital health and patient safety.

April 27, 2016

Alternative medications for medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug–Disease Interactions in the Elderly quality measures.

November 18, 2015

Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate.

September 5, 2012

A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics, etiologies, and outcomes.

June 18, 2014

Pediatric obesity and safety in inpatient settings: a systematic literature review.

May 21, 2014

Addressing patient safety in rapid response activations for nonhospitalized persons.

July 2, 2014

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analysis.

December 8, 2021

Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study.

November 24, 2021

Uptake of pharmacist recommendations by patients after discharge: implementation study of a patient-centered medicines review service.

May 3, 2023

A family and hospital's journey and commitment to improving diagnostic safety.

March 9, 2022

Under-reporting of deaths to the coroner by doctors: a retrospective review of deaths in two hospitals in Melbourne, Australia.

June 27, 2007

Hand-off Communications.

October 27, 2010

High-performance teams and the physician leader: an overview.

September 22, 2010

Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions.

May 26, 2010

Avoiding wrong site surgery: a systematic review.

May 26, 2010

Management of anesthesia equipment failure: a simulation-based resident skill assessment.

August 19, 2009

Evaluation of an electronic dosing calculator to reduce pediatric medication errors.

February 20, 2019

Emergency department discharge prescription interventions by emergency medicine pharmacists.

June 20, 2012

Natural language processing and its implications for the future of medication safety: a narrative review of recent advances and challenges.

September 5, 2018

Pediatric faculty knowledge and comfort discussing diagnostic errors: a pilot survey to understand barriers to an educational program.

June 12, 2019

Are personal health records (PHRs) facilitating patient safety? A scoping review.

June 15, 2022

Ten years later, alarm fatigue is still a safety concern.

September 20, 2023

Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA.

June 24, 2020

Recurrent obstetric management mistakes identified by simulation.

June 27, 2007

Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan.

March 28, 2007

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.

March 27, 2005

Race, postoperative complications, and death in apparently healthy children.

August 12, 2020

U.S. compounding pharmacy-related outbreaks, 2001--2013: public health and patient safety lessons learned.

June 17, 2015

ACOG SCOPE: Safety Certification in Outpatient Practice Excellence for Women's Health.

September 5, 2012

Preventing adverse events in cataract surgery: recommendations from a Massachusetts expert panel.

August 8, 2018

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.

August 6, 2014

Costs associated with surgical site infections in Veterans Affairs hospitals.

July 9, 2014

A medication-based trigger tool to identify adverse events in pediatric anesthesiology.

July 2, 2014

Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.

November 30, 2022

Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems.

January 13, 2021

Use of e-triggers to identify diagnostic errors in the paediatric ED.

April 6, 2022

Epidemiology of medication-related adverse events in nursing homes.

November 8, 2006

The 100,000 Lives Campaign: setting a goal and a deadline for improving health care quality.

January 25, 2006

Iatrogenic harm caused by diagnostic errors in fibrodysplasia ossificans progressiva.

November 23, 2005

Understanding diagnostic safety in emergency medicine: a case‐by‐case review of closed ED malpractice claims.

June 6, 2018

Pediatric emergency department discharge prescriptions requiring pharmacy clarification.

August 5, 2015

Using "near misses" analysis to prevent wrong-site surgery.

October 30, 2013

View More

Related Resources

Free-text computerized provider order entry orders used as workaround for communicating medication information.

August 31, 2022

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

March 30, 2022

Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations.

August 4, 2021

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

May 17, 2021

Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS.

April 21, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

WebM&M Cases

When the Indications for Drug Administration Blur

June 24, 2020

Effectiveness of double checking to reduce medication administration errors: a systematic review.

September 18, 2019

The wicked problem of patient misidentification: how could the technological revolution help address patient safety?

May 1, 2019

Implementation of bar-code medication administration to reduce patient harm.

February 20, 2019

What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff.

January 23, 2019

Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.

November 21, 2018

Blame: what does it look like?

November 14, 2018

Preventing medication errors in the information age.

September 5, 2018

Nurses' clinical reasoning practices that support safe medication administration: an integrative review of the literature.

January 10, 2018

White paper on recommendation for systems-based practice competency.

December 6, 2017

Workarounds are routinely used by nurses—but are they ethical?

November 8, 2017

Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.

July 26, 2017

Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors.

July 19, 2017

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

June 28, 2017

Teaching students to administer medications safely.

April 19, 2017

Is technology the best medicine? Three practice theoretical perspectives on medication administration technologies in nursing.

June 15, 2016

The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors.

April 27, 2016

The promise of big data: improving patient safety and nursing practice.

April 27, 2016

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.

February 3, 2016

Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses.

August 26, 2015

Workarounds in the workplace: a second look.

August 12, 2015

Understanding the causes of intravenous medication administration errors in hospitals: a qualitative critical incident study.

April 1, 2015

Factors contributing to Registered Nurse medication administration error: a narrative review.

March 18, 2015

View More

See More About The Topic

Information Professionals

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364