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- Communication Improvement 1
- Human Factors Engineering
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 1
- Alert fatigue 1
- Device-related Complications 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Safety 2
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
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.
Journal Article > Study
Enhancing patient safety with intelligent intravenous infusion devices: experience in a specialty cardiac hospital.
Wood JL, Burnette JS. Heart Lung. 2012;41:173-176.
Implementation of smart intravenous pumps was associated with fewer adverse events and considerable cost savings at an academic medical center.
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.
Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
Journal Article > Review
Smulyan H. Am J Med. 2019;132:153-160.