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Approach to Improving Safety
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Search results for "Active Errors"

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Journal Article > Study

Operational failures and interruptions in hospital nursing.

Tucker AL, Spear SJ. Health Serv Res. 2006;41:643-662.

This study discovered that nurses experienced more than eight work system failures during an 8-hour shift. Investigators combined primary observation with interview and survey methods to understand the role work system failures play on nurse effectiveness. The most frequent failures identified involved medications, orders, supplies, staffing, and equipment. In addition to operational failures that delayed productivity, a large number of reported work interruptions contributed to the study findings. The authors advocate for continued efforts to differentiate between tactics taken by bedside nurses to prevent error with tactics that result from the system (eg, interruptions), which often put patients at risk for error.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

This monthly selection of medication error reports discusses a mistake with chelation therapy agents due to similar acronym use, confusion of drugs similarly named in different countries, and inadequate information about changes to an existing drug.

Special or Theme Issue

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.

Journal Article > Study

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. J Patient Saf. 2016 Dec 21; [Epub ahead of print].

Interruptions are known to contribute to medication administration errors. This pre–post study found that nurses experienced fewer interruptions and made fewer medication errors following the introduction of a separate medication room. These results demonstrate how changing the work environment can promote safety.

Journal Article > Study

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

Jones A, Johnstone MJ. Aust Crit Care. 2017;30:219-223.

This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.

Journal Article > Study

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

Armstrong GE, Dietrich M, Norman L, Barnsteiner J, Mion L. J Nurs Care Qual. 2017;32:226-233.

Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.

Journal Article > Study

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

van Galen LS, Struik PW, Driesen BEJM, et al. PLoS One. 2016;11:e0161393.

Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.

Journal Article > Study

Effect of warning symbols in combination with education on the frequency of erroneously crushing medication in nursing homes: an uncontrolled before and after study.

van Welie S, Wijma L, Beerden T, van Doormaal J, Taxis K. BMJ Open. 2016;6:e012286.

Not all pill-form medications can be safely crushed to administer to patients who have difficulty swallowing. In this before and after intervention study in a nursing home, adding warning symbols and educating staff about crushing medications led to a decrease in pill-crushing errors. The authors conclude that education and warnings enhanced this aspect of medication safety.

Journal Article > Study

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

Soban LM, Kim L, Yuan AH, Miltner RS. J Nurs Manag. 2016 Aug 4; [Epub ahead of print].

Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment to hospitals. In this study, researchers surveyed chief nursing officers across Veterans Health Administration acute care hospitals to better understand how organizational strategies are operationalized with regard to implementing pressure ulcer prevention programs. They found that such strategies were not operationalized in a uniform manner across the hospitals and that nurse leadership played a substantial role in influencing the implementation of pressure ulcer prevention initiatives.

Journal Article > Commentary

Incorporating quality and safety values into a CLABSI simulation experience.

Liebrecht CM, Lieb MC. Nurs Forum. 2017;52:118-123.

Simulation has been promoted as a way to teach nurses about potential errors in their practice. This commentary describes the development of a program to help nurses recognize and correct weaknesses in their care processes that increase risk of central line–associated bloodstream infection.

Journal Article > Commentary

Preventing medication errors.

Stefanacci RG, Riddle A. Geriatr Nurs. 2016;37:307-310.

Nursing home patients are particularly vulnerable to medication errors. This commentary describes an incident involving a medication error and reviews conditions in long-term care that increase the potential for similar errors to occur. The authors suggest that proactive system improvements must address weaknesses in ordering, administration, compliance, and medication reconciliation.

Tools/Toolkit > Fact Sheet/FAQs

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

Horsham, PA: Institute of Safe Medication Practices; 2016.

Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.

Journal Article > Review

Systematic review and meta-analysis of educational interventions designed to improve medication administration skills and safety of registered nurses.

Härkänen M, Voutilainen A, Turunen E, Vehviläinen-Julkunen K. Nurse Educ Today. 2016;41:36-43.

Adverse drug events can result from errors in medication administration by nurses. This meta-analysis found that a broad range of nursing education interventions, from simulation to traditional didactic curricula, can improve the safety of medication administration. This suggests that multiple nursing educational strategies can be used to enhance inpatient medication safety.

Journal Article > Review

Nurses' role in medical error recovery: an integrative review.

Gaffney TA, Hatcher BJ, Milligan R. J Clin Nurs. 2016;25:906-917.

This review examined nurses' role in detecting, interrupting, and correcting medical errors at the point of care. According to some studies, nurses may recover as many as one error each shift. A strong safety culture was an important organizational enabler of effective error recovery.

Journal Article > Study

The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors.

Sears K, O'Brien-Pallas L, Stevens B, Murphy GT. J Pediatr Nurs. 2016;31:e283-e290.

This Canadian study found that nurses with more experience reported a greater number of pediatric medication administration errors, but these errors were less severe compared to other units. This finding suggests widespread underreporting of medication errors by nurses with a lower level of experience.

Journal Article > Commentary

Promoting patient safety with perioperative hand-off communication.

Robinson NL. J Perianesth Nurs. 2016;31:245-253.

Handoffs are comprised of a multitude of steps that are prone to communication error. This commentary describes how a hospital drew from Lean Six Sigma concepts to develop and implement a standardized handoff process. The effort achieved improvements and established a concrete method for nurses to apply safe communication and data sharing principles in the perioperative environment.

Journal Article > Review

Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration.

Hayes C, Jackson D, Davidson PM, Power T. J Clin Nurs. 2015;24:3063-3076.

This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.

Journal Article > Review

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.

Bergs J, Lambrechts F, Simons P, et al. BMJ Qual Saf. 2015;24:776-778.

This qualitative study enumerates barriers and facilitators to implementing checklists, but also confirms the importance of a shared safety culture in aligning different stakeholders—including surgeons, anesthesiologists, and nurses—to enable implementation.

Journal Article > Review

Concept analysis: wrong-site surgery.

Watson DS. AORN J. 2015;101:650-656.

Despite large-scale efforts to prevent wrong-site surgeries, they continue to occur. This concept analysis found limited evidence regarding the role of nurses in wrong-site surgery and recommends that future research focus on theoretical frameworks around how preoperative nurses can help avert these never events.

Cases & Commentaries

Unseen Perils of Urinary Catheters

  • Web M&M

Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RN; June 2015

A hospitalized older man with a complicated medical history had not voided in several hours. The patient voided just prior to catheter insertion, which produced no urine, and the nurse assumed that meant the patient's bladder was empty. Two hours later the patient complained of discomfort and a blood clot was found in his tubing. Continuous bladder irrigation was ordered, but the pain became worse. Urgent consultation by urology revealed that the urinary catheter was not in the bladder.

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