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Cases & Commentaries
- Web M&M
Vinod K. Bhutani, MD, and Ronald J. Wong; October 2017
A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.
Journal Article > Study
Feldman LS, Fuchshuber P, Jones DB, Mischna J, Schwaitzberg SD; FUSE (Fundamental Use of Surgical Energy) Task Force. Surg Endosc. 2012;26:2735-2739.
The majority of practicing surgeons surveyed in this study were unaware of risk factors and preventive methods for surgical fires.
Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors.
ISMP Medication Safety Alert! Acute Care Edition. March 13, 2014;19:1-2,4-5.
Summarizing results from a national survey investigating vaccine administration errors, this article outlines recommendations to reduce risks associated with the use and packaging of vaccines. Tips include establishing protocols for commonly used vaccines, requiring periodic training for staff, and labeling prepared syringes.
ISMP Medication Safety Alert! Acute Care Edition. May 22, 2014;19:1-2.
Errors occur frequently in vaccine administration when packaging instructions for diluents are unclear. This newsletter article offers recommendations for manufacturers and practitioners to reduce risks related to vaccines.