Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Specialization of Care
- Teamwork 1
Search results for ""
Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.
Comarow A. US News & World Report. July 18, 2005;139:74,76,79.
This article, accompanying the widely read ranking of "America's Best Hospitals," describes the Institute for Healthcare Improvement's 100,000 Lives Campaign. Focusing on the six practices promoted by the campaign, it reviews the progress to date, with a particular focus on two participating hospitals' (Hackensack University Medical Center in New Jersey and McLeod Regional Medical Center in South Carolina) experiences in implementing the practices.
McCarthy D, Blumenthal D. New York, NY: The Commonwealth Fund; April 2006.
This report presents ten case studies to illustrate interventions that address prominent and targeted areas for patient safety improvement. The five areas of focus include promoting an organizational safety culture, improving teamwork and communication, enhancing rapid response to inpatient crises, preventing health care–associated infections in intensive care units, and preventing hospital-based adverse drug events. The collection of stories represents a diverse group of health care organizations, with each sharing their approach to a given safety issue, the results achieved, and the lessons learned to assist others making similar efforts at their own institution. The authors also published an article about case studies in safety improvement.
Meyers S. Trustee. January 2007;60:6-10.
This article shares safety and quality initiatives implemented by several health care organizations in conjunction with the 100K Lives Campaign goals.
Journal Article > Commentary
Cooper BE. Am J Health Syst Pharm. 2007;64:694, 697-698.
The author describes one hospital's use of pharmacists as part of the rapid response team (RRT) and the pharmacists' perceptions of their effect on medication delivery decisions when the RRT was deployed.
Journal Article > Study
Lipshutz AKM, Morlock LL, Shore AD, et al. Jt Comm J Qual Patient Saf. 2008;34:46-56.
This study describes medication error types that occur in ''code'' situations and also highlights their impact on other patients (referred to as ''collateral damage errors'' by the authors). Using data from MEDMARX, a voluntary reporting database that tracks medication information from participating hospitals, investigators evaluated more than 2000 code-related errors. Omission errors were the most common error type, registered nurses and respiratory therapists were most frequently involved (though also the most likely to prevent errors), and anti-asthma/bronchodilator medications were the most common therapeutic class implicated. The authors provide a number of anecdotes to illustrate the relationship of the errors to the code situation, and detail the level of harm and common contributing factors reported. Finally, a series of preventive strategies are offered to reduce code-related medication errors, including redundant staffing to prevent collateral damage errors, and the use of DNR identification systems and rapid response systems to reduce code frequency.
ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.
This article provides screening, dosing, and monitoring recommendations for using basal opioid infusions and patient-controlled analgesia (PCA) in patients at risk for developing respiratory depression.
Journal Article > Study
Dailey MS, Durkin S, Gulczynski B, Kearney M, Loeb B, Pouliot J. Patient Saf Qual Healthc. Nov/Dec 2009;6:28-31.
This study discusses how analysis of rapid response team calls identified a recurrent pattern of medication errors, and describes the steps taken to prevent such errors.
Journal Article > Study
Gokhman R, Seybert AL, Phrampus P, Darby J, Kane-Gill SL. Resuscitation. 2012;83:482-487.
Despite increased adoption of computerized provider order entry, medication errors are a continued problem in acute care settings, particularly in high-risk ones such as intensive care units. These concerns are perhaps greatest for patients with acute clinical deterioration who need rapid resuscitative efforts. This study evaluated medication errors during activation of medical emergency teams. While the study was performed at a single site with a limited sample size, the findings of nearly 1 in 2 doses administered in error was alarming. More than 65% of errors involved breaks in aseptic technique, while nearly half of those remaining were prescribing errors. Almost 15% of errors were classified as at least moderate in severity, underscoring the need for greater attention to medication safety in these clinical situations.