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Search results for "Bar Coding and Radiofrequency ID Tagging"

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Legislation/Regulation > Sentinel Event Alerts

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission.

Web Resource > Government Resource

National Comparative Audit of Blood Transfusion.

National Blood Service Hospitals.

This Web site includes reports from audits on compliance with blood transfusion guidelines in the United Kingdom.

Cases & Commentaries

Moved Too Soon

  • Web M&M

Peter Lindenauer, MD, MSc; October 2004

A surgical patient and a neurosurgical patient are scheduled to be moved to different beds, the second taking the first's spot. However, the move is documented electronically before it occurs physically, and a medication error nearly ensues.

Journal Article > Review

Medication safety in the operating room: literature and expert-based recommendations.

Wahr JA, Abernathy JH III, Lazarra EH, et al. Br J Anaesth. 2017;118:32-43.

This Delphi study examined 138 recommendations, generated from a review of 74 studies, regarding medication safety in the operating room. Using a consensus process, investigators determined 35 practices that can be implemented in the operative setting, including medication reconciliation and barcoding.

Cases & Commentaries

The ECG Is Not Normal

  • Spotlight Case
  • Web M&M

Abigail Zuger, MD; June 2011

An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.

Journal Article > Commentary

Principles of conservative prescribing.

  • Classic

Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Arch Intern Med. 2011;171:1433-1440.

Strategies to prevent medication errors are an ongoing focus in patient safety. Computerized provider order entry, medication reconciliation, avoidance of drug–drug interactions, and bar-coded medication administration are a few areas generating significant attention. This commentary discusses an alternate approach to medication safety, focusing on prevention of prescribing unnecessary medications at the outset. The authors provide a set of principles that urge clinicians to: think beyond drugs, practice more strategic prescribing, maintain heightened awareness about side effects, exercise skepticism about new drugs, work with patients for a shared agenda, and consider long-term impacts of medications prescribed. Each of these principles is discussed and sets the background for a recommendation to shift current paradigms in prescribing from "newer and more is better" to "fewer and more time tested is best."

Cases & Commentaries

Pocket Syringe Swap

  • Web M&M

John C. Kulli, MD; May 2011

A surgery fellow put two syringes in his pocket: one containing leftover anesthetic and one with agents to reverse it. When it came time to reverse the neuromuscular block, he administered the anesthetic by mistake.

Tools/Toolkit > Fact Sheet/FAQs

Preventing Medication Errors: A $21 Billion Opportunity.

  • Classic

Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.

This briefing sheet reviews the opportunities, solutions, and drivers for medication safety improvements.

Newspaper/Magazine Article

Catching deadly drug mistakes.

Landro L. Wall Street Journal. January 18, 2010;D5.

This column highlights the work of the Institute for Safe Medication Practices and other groups to raise awareness of medication safety issues, including an initiative to distribute error reports to practitioners, called the National Alert Network for Serious Medication Errors.

Newspaper/Magazine Article

Beyond the count: preventing the retention of foreign objects.

PA-PSRS Patient Saf Advis. June 2009;6:39-45.

This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.

Newspaper/Magazine Article

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

ISMP Medication Safety Alert! Acute Care Edition. May 21, 2009;14:1-3.

This article shares results from a survey regarding look-alike or sound-alike (LASA) medication confusion and lists strategies to reduce such errors.

Newspaper/Magazine Article

Piecing together medication administration.

Anderson HJ. Health Data Manage. May 1, 2009;17:22.

This article discusses efforts to support medicine administration through various information technology techniques. It is second in a three-part series on patient safety and computerization.

Cases & Commentaries

Eptifibatide Epilogue

  • Web M&M

William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009

A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:960-964.

This monthly selection reports on pump programming errors that led to overdoses of patient-controlled analgesia (PCA), miscommunication regarding dose and indication for alteplase, and a warning to not use empty prelabeled syringes.

Cases & Commentaries

Mistaken Identity

  • Web M&M

Leslie W. Hall, MD; October 2008

Orthopedic surgeons rounding on an elderly Cantonese-speaking woman recommend conservative, nonsurgical treatment for her broken hip, as their examination noted that the patient was able to walk. Given that strict bed rest orders were in place for this patient, a medical intern found the note peculiar. Further investigation revealed that the surgeons had actually walked the patient's roommate, another Cantonese-speaking woman.

Newspaper/Magazine Article

Epidural-IV route mix-ups: reducing the risk of deadly 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.

Cases & Commentaries

Elopement

  • Spotlight Case
  • Web M&M

Debra Gerardi, RN, MPH, JD; December 2007

An inpatient missing from his room is found several hours later outside the emergency department. Despite having arrived at the ED in a hospital gown with an inpatient ID bracelet, the patient is treated in the ED and discharged.

Newspaper/Magazine Article

The best medical care in the U.S.

Arnst C. Business Week. July 17, 2006.

This article discusses improvements made at U.S. Veterans Affairs' hospitals as well as unique elements of the system that support safe and high-quality care.

Cases & Commentaries

Over Not So Easy

  • Web M&M

Russ Cucina, MD, MS; July 2006

Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.

Newspaper/Magazine Article

Tomorrow's operating room to harness Net, RFID.

Olsen S. CNET News.com; October 19, 2005.

This article describes the "OR of the Future" initiative at Massachusetts General Hospital. The project uses advanced technology to provide patient information in the operating room.

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