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Perspectives on Safety > Perspective
with commentary by Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN, Bar Coding for Medication Safety, September 2008
Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
Risk of electromagnetic interference with medical telemetry systems operating in the 460-470 MHz frequency bands.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 16, 2005.
This announcement notifies health care practitioners of possible interference with medical alarms and patient monitoring systems caused by mobile radio transmitters.
Gehlot V, Sloane EB. Computer. April 2006;39:54-60.
The authors discuss clinical alarm systems from a technical perspective and propose a toolkit to help make complex clinical IT systems more technically reliable.
Journal Article > Commentary
Vanderveen T. Patient Saf Quality Healthc. January/February 2007.
The author discusses high-risk intravenous infusions, smart pump technologies that support safe delivery of medications, and effective use of smart pump data to inform improvements.
This article reports on two projects developed at the Center for Integration of Medicine and Innovative Technology that demonstrate functional device interoperability in hospital operating rooms.
Kowalczyk L. Boston Globe. February 21, 2010.
This news account discusses a patient death after a heart monitor alarm was inadvertently turned off. Hospital and device safety experts weigh in on strategies to prevent these types of errors.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
Journal Article > Study
Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients.
Drew BJ, Harris P, Zègre-Hemsey JK, et al. PLoS One. 2014;9:e110274.
Alarm fatigue, in which clinicians ignore safety alerts if they are too frequent or perceived to be clinically irrelevant, can lead to lack of awareness of an unsafe situation. This concern is particularly acute in intensive care units where patients are typically monitored with multiple devices, each with alarms. This retrospective review examined all alarm data regarding physiologic monitoring, including electrocardiogram, blood pressure, and oxygenation, from five intensive care units in a medical center. The vast majority of alarms were false-positives. Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable events were common causes for unnecessary alarms. The authors call for improving device design and monitor algorithms in order to reduce alarm fatigue. A previous AHRQ WebM&M perspective discussed the safety of medical devices.
Journal Article > Commentary
Thimbleby H, Lewis A, Williams J. Clin Med. 2015;15:258-262.
Design weaknesses for medical devices can remain unrecognized due to insufficient reporting and the tendency to place blame on the user rather than question whether the equipment functioned appropriately. Discussing flaws in health IT design and how they can contribute to patient harm, this commentary advocates for enhanced reporting of device-related incidents to raise awareness about risks and enable learning from errors.
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
Smart pumps offer both benefits and drawbacks that can affect medication safety. This newsletter article explores missteps related to lack of compliance with setting hard stops to protect patients when using unique intravenous medication concentrations. Recommendations to prevent errors include using standardized dosing concentrations as often as possible, adhering to metric unit dosing requirements, and verifying pump programming settings.