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Search results for "Active Errors"

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Journal Article > Commentary

Farewell to a cancer that never was.

Lyon J. JAMA. 2017;317:1824-1825.

Overdiagnosis can result in financial, psychological, and physical harm for patients. This commentary discusses the reclassification of a subtype of thyroid cancer as a nonmalignancy and the impact changing guidelines can have on patients.

Cases & Commentaries

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Cases & Commentaries

The Empty Bag

  • Web M&M

Chris Vincent, PhD; December 2016

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

Book/Report

Global Guidelines on the Prevention of Surgical Site Infection.

Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.

Book/Report

Avoiding Unconscious Bias: a Guide for Surgeons.

London, UK: Royal College of Surgeons of England; 2016.

Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.

Journal Article > Commentary

Access to prescription opioids—Primum Non Nocere: a teachable moment.

Tyler PD, Larochelle MR, Mafi JN. JAMA Inter Med. 2016;176:1251-1252.

Insufficient medication counseling and suboptimal prescribing practices contribute to misuse of opioids among patients. Describing a patient who became addicted to prescription opioids as a teenager after finding the medication at home, this commentary illustrates how current prescribing guidelines can address the opioid epidemic in the United States.

Newspaper/Magazine Article

Correct use of inhalers: help patients breathe easier.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.

Patients and clinicians can make medication administration mistakes when new drug delivery mechanisms are introduced. This newsletter article reviews common errors associated with the use of inhalers and offers recommendations for patients, nurses, respiratory therapists, pharmacists, and health care organizations to educate patients on the use of these medications.

Journal Article > Commentary

Guideline implementation: prevention of retained surgical items.

Fencl JL. AORN J. 2016;104:37-48.

Although incidents involving retained surgical items are rare, they continue to occur. This commentary reviews guidance for perioperative nurses to reduce risks of this sentinel event. The author outlines steps to improve safety such as team accountability, standardized surgical sponge counts, and reconciling count discrepancies.

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 > Study

Standardization of compounded oral liquids for pediatric patients in Michigan.

Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.

When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.

Journal Article > Commentary

Recommended responsibilities for management of MR safety.

Calamante F, Ittermann B, Kanal E, Norris D; Inter-Society Working Group on MR Safety. J Magn Reson Imaging. 2016;44:1067-1106.

Magnetic resonance safety events can lead to serious patient harm. This commentary provides recommendations from expert consensus to help organizations design and implement a range of magnetic resonance imaging services. The authors also define three levels of management responsibilities required to support those recommendations in a various settings.

Web Resource > Multi-use Website

Standardize 4 Safety.

American Society of Health-System Pharmacists.

Standardization has been highlighted as a way to improve safety in surgery, care transitions, and medication administration. This initiative seeks to develop consensus guidelines and a set of standard concentrations to reduce errors associated with concentrations and dosing of liquid medications. The process for submitting comments on the first set of materials is open.

Book/Report

Antibiotic Stewardship in Acute Care: A Practical Playbook.

National Quality Partners. Washington, DC: National Quality Forum; 2016.

Antimicrobial stewardship has been promoted as a strategy to improve patient safety by reducing overuse of antibiotics to prevent hospital-acquired infections. This report draws from the experience of existing programs to summarize practical strategies for implementing initiatives. Core elements include engaging leadership, monitoring effectiveness, and reporting benchmarks.

Cases & Commentaries

Mismanagement of Delirium

  • Web M&M

Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS; May 2016

An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.

Cases & Commentaries

Picking Up the Cause of the Stroke

  • Web M&M

Vineet Chopra, MD, MSc; February 2016

Hospitalized with poorly controlled diabetes, a man had a peripherally inserted central catheter (PICC) placed for intravenous pain medications, intravenous fluids, and parenteral nutrition. The next day, the patient complained of headache, unilateral vision loss, and left-sided tingling and numbness. Misplacement of the PICC in a left-sided superior vena cava had led to embolic strokes.

Book/Report

2016–2017 Targeted Medication Safety Best Practices for Hospitals.

Horsham, PA: Institute for Safe Medication Practices; 2015.

This updated report outlines 11 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to storage and use of neuromuscular blocking agents, smart pumps, and standardized protocols for rescue agents.

Book/Report

National Safety Standards for Invasive Procedures (NatSSIPs).

NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.

Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.

Press Release/Announcement

ISMP Survey on Implementation of the 2016–2017 Targeted Medication Safety Best Practices for Hospitals.

Horsham, PA: Institute for Safe Medication Practices. 

This survey seeks to assess the implementation of consensus-based best practices to improve medication safety in health care facilities. The deadline for submitting responses is July 21, 2017.

Newspaper/Magazine Article

Reminder: pay attention to the appearance of your medicines.

ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.

This newsletter article describes an incident involving a patient who noticed that the tablets in her prescription refill had a different marking than usual, alerting her that she might have received an incorrect medication which was confirmed by the pharmacist. Tips for patients to avoid medication errors include being familiar with how their medicines look and checking prescriptions before leaving the pharmacy. Practitioners can help prevent these errors by counting and labeling prescriptions one at a time and performing patient consultations.

Cases & Commentaries

A Stroke of Error

  • Spotlight Case
  • CME/CEU
  • Web M&M

Kevin M. Barrett, MD, MSc; December 2014

An elderly man admitted for a presumed hypertensive emergency and undiagnosed neurologic symptoms became unresponsive and was noted to have new right hand weakness 2 days into his hospitalization. After a "Code Stroke" was called, a neurologist evaluated him and administered tPA 100 minutes after the acute event. A few hours later, the patient developed further symptoms, and an emergent head CT demonstrated post-tPA intracerebral hemorrhage.

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