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Journal Article > Commentary
Systems approach and systems engineering applied to health care: improving patient safety and health care delivery.
Ravitz AD, Sapirstein A, Pham JC, Doyle PA. Johns Hopkins APL Tech Dig. 2013;31:354-365.
Journal Article > Study
Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting.
Pinkney SJ, Fan M, Koczmara C, Trbovich PL. Crit Care Med. 2019;47:e597-e601.
This simulation study examined critical care unit nurses' performance in identifying intravenous medications using different equipment types. Researchers found that line labels (attached to each line of tubing) and organizers (which prevent tubing from tangling) significantly improved the accuracy of medication identification compared to usual care. Use of smart pumps required more time and did not improve medication identification accuracy, suggesting that line labels and organizers are an inexpensive and feasible method to enhance medication safety.