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Audiovisual > Slideset
Denver, CO: Association of periOperative Registered Nurses (AORN); 2005.
This toolkit focuses on medication error in the surgical unit and includes self-assessments, a poster, pocket guide, and educational CD-ROM. Contact hours are available to nurses for successful completion.
Journal Article > Study
Nonpunitive medication error reporting: 3-year findings from one hospital's primum non nocere initiative.
Potylycki MJ, Kimmel SR, Ritter M, et al. J Nurs Adm. 2006;36:370-376.
The investigators conducted a survey to inform the implementation of a nonpunitive medication error reporting policy and educational workshop. A comparison to post-initiative findings revealed that staff perception of reporting improved after the educational initiative.
Journal Article > Study
Kliger J, Singer S, Hoffman F, O'Neil E. Jt Comm J Qual Patient Saf. 2012;38:51-60.
While quality improvement projects can result in short-term, local success, ensuring the sustainability and spread of successful interventions can be extremely challenging. This follow-up study describes methods used to disseminate a successful project to reduce medication administration errors beyond the original pilot hospitals. The article details how stratiegies for communication, local adaptation, teamwork, and learning from failure were essential to implementing the intervention across a broad range of hospitals. This approach achieved sustained improvement in medication administration error rates in both the initial and subsequent groups of hospitals.
At the Precipice of Quality Health Care: The Role of the Toxicologist in Enhancing Patient and Medication Safety.
J Med Toxicol. 2015;11:165-166, 252-273.
This special issue highlights proceedings from a conference that explored the intersection of toxicology and patient safety improvement. Articles explore how toxicologists can contribute to medication safety efforts through simulation training, collaborating with organizations such as poison control centers, and utilizing communication tools to enhance teamwork.
Journal Article > Review
A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?
Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.
Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.
Journal Article > Review
Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.
Strudwick G, Reisdorfer E, Warnock C, et al. J Nurs Care Qual. 2018;33:79-85.
Schnell M, Currie J. Cambridge, MA: National Bureau of Economic Research; August 2017. Working Paper No. 23645.
Overprescribing is seen as a contributor to the current opioid epidemic. This working paper explores the potential role that physician education and medical school quality have on prescribing behaviors. Analyzing data from 2006–2014, the authors found that lower ranked institutions wrote more opioid prescriptions and conclude that physician education may be a logical focus of improvement efforts. A recent PSNet perspective explored opioid overdose as a patient safety problem.
Journal Article > Commentary
Guenter P, Worthington P, Ayers P, et al; Parenteral Nutrition Safety Committee, American Society for Parenteral and Enteral Nutrition. Nutr Clin Pract. 2018;33:295-304.
Administration of parental nutrition is a specialized process that requires distinct competencies to be safe. This guideline recommends standardized competencies for clinicians to develop and maintain to ensure safe and reliable administration of parenteral nutrition therapy in various care environments and team configurations.
Porter S. HealthLeaders Media. April 26, 2018.
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medication overdose that led to the death of a patient with dementia, this news article describes how the hospital changed their processes to improve medication safety, which included restructuring medication safety leadership, modifying the electronic health record to address alert overrides, and enhancing information sharing to support learning and transparency.