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Journal Article > Study
Prewitt J, Schneider S, Horvath M, Hammond J, Jackson J, Ginsberg B. J Patient Saf. 2013;9:103-109.
Patient-controlled analgesia (PCA) devices were designed to provide safe administration of opiate analgesics, but PCA-related medication errors do still occur. Due to the dangers associated with opiate use, these errors can be fatal. This study provides a retrospective review of PCA adverse drug events at Duke University Hospital before and after implementation of clinical decision support with computerized provider order entry and PCA smart pump technology. The rate of adverse drug events per 1000 patient PCA days decreased from 5.3 (pre-intervention) to 4.2 (post-intervention). This modest but important improvement supports medical centers' investment in these strategies. A prior AHRQ WebM&M commentary discusses a case of a fatal PCA overdose.
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
Journal Article > Study
Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues.
DesRoches CM, Rao SR, Fromson JA, et al. JAMA. 2010;304:187-193.
Patient safety initiatives will increasingly balance the tension between systems change and individual accountability, and medical professionalism is often at the center of this discussion. Although certain behaviors in medical school predict unprofessional behavior, efforts to teach these skills have been described, particularly in addressing disruptive behavior. This study surveyed physicians and found that nearly 70% believe that it is their professional responsibility to report an impaired or incompetent colleague. However, of those with knowledge of such a colleague, 33% failed to report them to a relevant authority. Barriers to reporting included a belief that it wasn't their responsibility, nothing would happen from reporting them, and fear of retribution. A related editorial discusses medical professionalism in the context of this study's findings and weighs different strategies to address the challenges. A past AHRQ WebM&M conversation and commentary also discuss professionalism and patient safety.
Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.