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Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Specific to High-Risk Drugs
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
Quick Safety. April 15, 2019;(48):1-3.
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the patient safety impacts of drug diversion among health care workers and notes the importance of a culture of constructive reporting to uncover and address this unsafe behavior.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Dembosky A. All Things Considered and KQED. January 23, 2019.
Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
Look-alike and sound-alike medications present a recurring threat to patient safety. This newsletter article summarizes an analysis of reported drug name confusion errors. Although incidents seem to have decreased over time, the influx of generic drug names is contributing to the persistence of the problem. Increased federal attention to the issue, provider use of known strategies to improve practice, and pharmaceutical company testing of names to avoid similarities can help reduce drug name confusion.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Bartolone P. Kaiser Health News. March 16, 2018.
Drug shortages may require clinicians, pharmacists, and hospitals to divert from standard processes to address gaps. This news article reports how reduced opioid production as an approach to address the opioid crisis has led to shortages and subsequent patient harm, such as insufficient pain management for surgical, cancer, and trauma patients.
Daley J. Colorado Public Radio. February 23, 2018.
Innovations in the prescribing of opioids in the emergency department are needed to change practice and help address the opioid crisis. This news article reports the results of a 10-hospital pilot program, the Colorado Opioid Safety Collaborative, which used alternative pain control approaches to reduce opioid prescriptions by an average of 36%. The program builds on multidisciplinary teamwork to modify pain management in the emergency department. An Annual Perspective highlighted opioid misuse as a patient safety challenge.
Quick Safety. October 16, 2017;(37):1-3.
Blank C. Drug Topics. October 13, 2017.
William Brangham. PBS News Hour. September 29, 2017.
Bendix J. Med Econ. September 25, 2017.
The persistent problem of opioid-related harm calls for changes in pain management practices and system processes in all care settings. This magazine article reports on ways physicians can help proactively recognize and address the potential for patient opioid misuse, such as adherence to guidelines and monitoring patient opioid use. An Annual Perspective discussed the opioid crisis as a patient safety problem.
R3 Report. 2017 Aug 29;11:1-7.
Carr S. ImproveDx. April 2017;4:1-4.
Hoffman J. New York Times. June 10, 2016.
Overprescribing of opioids for pain management contributes to the growing crisis involving opioid-related harm. This newspaper article reports on one hospital's efforts to avoid opioid use for patients presenting to the emergency department with pain. Alternative treatments included nonnarcotic infusions, nitrous oxide, music therapy, and holistic techniques.
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2016;21:1-4.
Insulin is a high-alert drug, and its use is becoming more complex due to the insulin resistance in diabetic patients with obesity. This newsletter article describes the experience of one hospital system that worked to ensure safe insulin administration by implementing a strategy that combined single-use pens and health information technology.