Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 1
- Education and Training 3
- Error Reporting and Analysis 1
- Human Factors Engineering 10
- Legal and Policy Approaches 4
- Logistical Approaches 4
- Quality Improvement Strategies 2
- Specialization of Care 1
- Technologic Approaches
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Interruptions and distractions 1
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 13
- Second victims 1
- Health Care Executives and Administrators 15
Health Care Providers
- Nurses 8
- Non-Health Care Professionals 10
- Patients 4
Search results for "Newspaper/Magazine Article"
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
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.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.
This piece describes how reliability science can be applied to barcoded medication administration (BCMA) and discusses the results of one hospital's AHRQ-funded BCMA project.
ISMP Medication Safety Alert! Acute Care Edition. June 30, 2011;16:1-2.
This article discusses problems associated with overreliance on barcode system audio confirmation and suggests strategies to improve the reliability of electronic medication administration systems.
ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.
This article reports results from a survey on the Centers for Medicare & Medicaid Services "30-minute rule" and provides a set of revised guidelines.
ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.
This piece highlights nurses' responses to a national survey that explored problems associated with the Centers for Medicare and Medicaid Services (CMS) medication administration timing requirement.
Colliver V. San Francisco Chronicle. October 28, 2009:A1.
This news story shares the results of a nine-hospital program to improve the safety of medication delivery through minimizing nursing interruptions.
ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
This article reports on an overdose caused by improper label placement on a patient controlled analgesia (PCA) pump and provides recommendations for preventing pump-related medication errors.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
US News & World Report. July 3, 2008.
This article discusses the findings of a recent study that reported deficiencies in barcode systems requiring numerous overrides and "workarounds" by nurses.
Health IT implementation stories: HANDS care plan tool seeks to improve nurse communication at handoff in AHRQ-funded study.
AHRQ National Resource Center for Health Information Technology.
This article describes an AHRQ-funded project to discern whether a standardized, computerized tool can improve handoff communication.
Gebhart F. Drug Topics (Health-System Edition). July 23, 2007.
This article describes how robust drug libraries developed for programmable smart pumps can help reduce medication errors associated with traditional infusion methods.
Swenson D. Patient Saf Qual Healthc. May/June 2007;4:18-25.
The author describes the new generation of barcode technologies that support safe bedside medication delivery and best practices for implementing barcode point of care systems.
Health Manage Techol. April 2007;28:30-32, 34.
This article describes a health system's implementation of bar coding technology to support safe medication administration.
ISMP Medication Safety Alert! Acute Care Edition. February 22, 2007;12:1-3.
This article lists common risks associated with opiates, a high-alert medication, as well as recommended safety improvements to reduce these risks.
Manic for medication safety: bar codes and drug information databases are helping to reduce medication errors.
Rogoski RR. Health Manage Technol. February 2007;28:14, 16-18.
This article discusses how various technologies have been used in the field to help prevent medication errors.
Newsweek. October 16, 2006:44-68, 72.
This "Health for Life" series features 10 case studies about patient safety and quality improvement efforts as well as several short articles on safety-related topics such as disclosure and computerizing medical care.
Dembner A. Boston Globe. July 3, 2006;Health Science section:A1.
This article reports on the movement to improve care in nursing homes in order to decrease unnecessary hospitalizations for elderly patients.