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Cases & Commentaries
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Saul N. Weingart, MD, PhD; August 2006
In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
Journal Article > Commentary
Saxena S, Kempf R, Wilcox S, et al. Jt Comm J Qual Patient Saf. 2005;31:495-506.
The authors applied failure mode effects and criticality analysis to improve laboratory value notification processes with non-emergent areas of care in a teaching hospital.
Journal Article > Study
Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.
The authors analyzed more than 80 communication breakdowns identified in a past review of surgical malpractice claims. The breakdowns took place with similar frequency in the preoperative, operative, and postoperative periods, and more than 70% involved a single communication failure. Attending surgeons were most commonly a part of the breakdowns, while ambiguity in the communicated roles and responsibilities contributed to more than half the events overall. Based on the findings, the authors developed a series of triggers that would prompt a direct communication with the attending surgeon. In addition, the authors advocate for greater use of structured protocols to address handoffs and transfers in care, times at which communication is critical and errors common.
ISMP Medication Safety Alert! Acute Care Edition. May 18, 2017;22:1-4.
Verbal orders are known to increase risk of error in care. This newsletter article summarizes survey results that sought to characterize current verbal order behaviors. Notably, practices to improve the reliability of verbal orders such as read backs were not optimally integrated in medication processes. The article includes recommendations for organizations, individuals, and teams to improve the safety of verbal orders.
Journal Article > Review
Yorkgitis BK, Brat GA. Am J Surg. 2018;215:707-711.
Use of mnemonics to recall standardized steps can help augment reliability. This review discusses the development of the RIGHTT mnemonic (Risk for adverse event, Insight into pain, Going over pain plan, Halting opioids, Tossing unused opioids and Trouble identification) designed to help surgeons improve safety of opioid prescribing for surgical pain.