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- Communication Improvement 12
- Culture of Safety 5
- Education and Training 4
- Error Reporting and Analysis 8
- Human Factors Engineering 8
- Legal and Policy Approaches 3
- Logistical Approaches 3
- Quality Improvement Strategies
- Specialization of Care 3
- Teamwork 4
- Clinical Information Systems 7
- Device-related Complications 5
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors 3
- Medical Complications 8
- Medication Errors/Preventable Adverse Drug Events 24
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 5
- Internal Medicine 20
- Nursing 4
- Pharmacy 9
- Health Care Executives and Administrators
Health Care Providers
- Nurses 10
- Physicians 13
- Non-Health Care Professionals 14
- Patients 3
Search results for "Newspaper/Magazine Article"
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
ED Manag. June 2016;28:S1-S4.
ISMP Medication Safety Alert! Acute Care Edition. November 6, 2014;19:1-4.
Despite the designation of proper labeling as a National Patient Safety Goal in 2006, the problem of unlabeled solutions and medications persists. This newsletter article outlines several incidents involving labeling issues that contributed to patient harm or death and provides strategies to reduce risks related to poor labeling practices, including ensuring labels are available in all settings that require them, using tall man lettering to differentiate look-alike drug names, and limiting access to solutions and medications.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.
ISMP Medication Safety Alert! Acute Care Edition. October 9, 2014;19:1-5.
Changes in practice require time and monitoring to achieve lasting improvements. This newsletter article highlights issues that continue to hinder medication safety, including inconsistent availability of patient counseling, misuse of prefilled syringes, and disrespectful behavior toward both peers and patients.
ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.
To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.
Fibuch E, Ahmed A. Physician Exec. Jul-Aug 2014;40:28-32.
Failure mode and effects analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system flaws. This article reviews the initial purpose of FMEA, provides a breakdown of the process, describes a scoring tool applying Six Sigma designations to determine probability of failure, and discusses how FMEA is used in health care settings.
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
This newsletter article reports results of a survey indicating when and why intravenous (IV) medications are unnecessarily diluted and makes recommendations to prevent this practice, such as including instructions in the medication administration record regarding dilution and educating nurses about risks. Medications were frequently diluted, which may lead to mislabeled syringes, IV medication contamination, and dosing errors.
Multifaceted initiative to reduce "alarm fatigue" on cardiac unit reduces alarms and increases nurse and patient satisfaction.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.
Wright J. Nursing Times. 2013;109:11-14.
This record review study found that omitted doses of antimicrobial medications occur frequently in hospital settings in the United Kingdom.
Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0.
ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013;18:1-4.
This newsletter article discusses risks associated with vincristine administration, contributing factors, and strategies to prevent errors.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Galli BJ, Riebling N, Paraso C, Lehmann G, Yule M. Patient Saf Qual Healthc. July/August 2013;10:36-41.
ISMP Medication Safety Alert! Acute Care Edition. June 13, 2013;18:1-4.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
ISMP Medication Safety Alert! Acute Care Edition. April 4, 2013;18:1-5.
This newsletter article recommends that high-alert medication lists be updated and reviewed regularly to ensure their efficacy in preventing errors and offers other strategies to reduce risks associated with medication use.
CDC Vital Signs. March 2012:1-4.
This newsletter article and accompanying set of infographics describes strategies to help patients and health care providers prevent health care–associated infections.
Joint Commission: The Source. January 2012;10:5-6.
This piece recommends tactics to ensure medications, medication containers, and other solutions are correctly labeled in compliance with the 2012 National Patient Safety Goals.
ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.
This newsletter article reveals system failures that contribute to continued drug name confusion, even after authorities have been notified of the problem.
Stockmeier C, Clapper C. Patient Saf Qual Healthc. September/October 2011;8:30-31,34-36.
This article reports on organizations that have implemented daily check-ins among hospital leaders as a tactic to improve safety.