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Cases & Commentaries
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David M. Gaba, MD ; October 2004
A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air.
Journal Article > Study
Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.
Koch SH, Weir C, Haar M, et al. J Am Med Inform Assoc. 2012;19:583-590.
The commonly used expression "missing the forest for the trees" is a shorthand summary of the concept of situational awareness—the degree to which a clinician's perception matches reality. Situational awareness requires that clinicians can perceive the information they need, comprehend the importance of this information, and forecast the implications of this information (i.e., adverse consequences that might happen). Nurses' role in patient safety is largely dependent on maintaining situational awareness, and this study used direct observation of intensive care unit (ICU) nurses in three hospitals to assess the degree to which monitoring devices and other information displays supported each phase of situational awareness. The authors found that the design of bedside information displays often impaired nurses' ability to gather critical patient data, particularly around medications, resulting in the potential to harm situational awareness. The authors make recommendations, based on human factors engineering principles, to improve the quality of information displays in the ICU.
Journal Article > Review
Browne M, Cook P. Nurs Crit Care. 2011;16:92-98.
This review explores how placing inappropriate trust in the reliability of complex equipment in the ICU may pose patient safety risks.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.