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- Communication Improvement 2
- Education and Training
- Error Reporting and Analysis 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies 2
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 5
- Medication Safety 4
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Cases & Commentaries
- Web M&M
Nancy Staggers, PhD, RN; October 2017
Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.
Chicago, IL: Health Research & Educational Trust; July 2013.
Journal Article > Study
Pugliese G, Gosnell C, Bartley JM, Robinson S. Am J Infect Control. 2010;38:789-798.
This study surveyed more than 5000 providers who reported elements of unsafe injection practices, including use of single-dose/use vials for more than one patient, and reuse of syringes.
Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors.
ISMP Medication Safety Alert! Acute Care Edition. March 13, 2014;19:1-2,4-5.
Summarizing results from a national survey investigating vaccine administration errors, this article outlines recommendations to reduce risks associated with the use and packaging of vaccines. Tips include establishing protocols for commonly used vaccines, requiring periodic training for staff, and labeling prepared syringes.
ISMP Medication Safety Alert! Acute Care Edition. May 22, 2014;19:1-2.
Errors occur frequently in vaccine administration when packaging instructions for diluents are unclear. This newsletter article offers recommendations for manufacturers and practitioners to reduce risks related to vaccines.
Journal Article > Review
Liang SY, Theodoro DL, Schuur JD, Marschall J. Ann Emerg Med. 2014;64:299-313.
Emergency care presents risks of health care–associated infection (HAI) for both clinicians and patients. This review provides an overview of HAIs in the emergency setting, including standard precautions meant to prevent the spread of infections, strategies to reduce risk of HAIs related to medical device use, and the evidence around effectiveness of prevention programs.
CDC Vital Signs. August 23, 2016.
Meeting/Conference > United States Meeting/Conference
Joint Commission Resources Quality and Safety Network. October 24, 2019, 2:00–3:00 PM (Eastern).