Narrow Results Clear All
- Communication Improvement 7
- Culture of Safety 2
Education and Training
- Students 1
- Error Reporting and Analysis 7
- Human Factors Engineering 18
- Legal and Policy Approaches 11
- Logistical Approaches 6
- Policies and Operations 1
- Quality Improvement Strategies 10
- Specialization of Care 1
- Technologic Approaches 17
- Device-related Complications 3
- Discontinuities, Gaps, and Hand-Off Problems 5
- Drug shortages 1
- Identification Errors 1
- Interruptions and distractions 3
- Medical Complications 3
- Medication Errors/Preventable Adverse Drug Events 36
- Psychological and Social Complications 3
- Second victims 2
- Surgical Complications 1
- Internal Medicine 11
- Pharmacy 20
- Family Members and Caregivers 1
- Health Care Executives and Administrators 34
Health Care Providers
- Nurses 19
- Non-Health Care Professionals 16
- Patients 10
Search results for "Medication Safety"
ISMP Medication Safety Alert! Acute Care Edition. January 25, 2007;12:1.
This article discusses the weaknesses inherent in using the "five rights" for medication use as absolutes and suggests that they instead serve as broad goals to support safe medication practices.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
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.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.
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.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Karch AM. Am Nurs Today. September 2015;10:18-22.
The complexity of care delivery can hinder the role of nurses in preventing medication errors. This commentary advocates for updating the five rights to consider the patient's role in their medication therapy and to incorporate patient and family education into the process to improve medication safety.
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
High-alert medications have the potential to cause serious patient harm. This article focuses on four primary types of high-alert medications—anticoagulants, sedatives, insulins, and opioids—that can have serious adverse effects and recommends strategies to reduce risks, including conducting independent double-checks and decreasing interruptions.
ISMP Medication Safety Alert! Acute Care Edition. April 9, 2015;20:1,4.
This newsletter article reports on issues related to a legislation, drafted in response to a tenfold dosing error, that would discipline nurses involved in medication errors. One particular concern highlighted is that the bill does not recognize the role of human error and systems failure in mistakes that result in patient harm.
ISMP Medication Safety Alert! Acute Care Edition. November 20, 2014;19:1-3.
Reviewing an incident involving a patient who reported an error with home infusion of chemotherapy which was later determined to be a false alarm, this newsletter article outlines actions that could have been taken to prevent wasted resources and anxiety for the patient and health care providers.
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
This newsletter article reports results of a survey indicating when and why intravenous (IV) medications are unnecessarily diluted and makes recommendations to prevent this practice, such as including instructions in the medication administration record regarding dilution and educating nurses about risks. Medications were frequently diluted, which may lead to mislabeled syringes, IV medication contamination, and dosing errors.
Eggertson L. Can Nurse. March 2014;110:25-29.
Human factors engineering is being increasingly promoted as an approach that generates lasting safety improvements. This commentary describes how applying human factors principles can identify ways to reduce risks in health care settings, including issues related to interruptions and infusion pumps.
ISMP Medication Safety Alert! Acute Care Edition. February 27, 2014;19:1-4.
Summarizing results from a Canadian study to determine factors associated with fatal medication errors in the home, this newsletter article describes how patients and nonprofessional caregivers lacked understanding about their medication, such as potential adverse effects and signs of toxicity, which increased risk of harm.
Jones R. WXYZ. November 13, 2013.
This news piece reports on risks associated with medication delivery in nursing homes and reveals several incidents that resulted in significant patient harm.
ISMP Medication Safety Alert! Acute Care Edition. June 13, 2013;18:1-4.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.
ISMP Medication Safety Alert! Acute Care Edition. February 9, 2012;17:1-4.
This newsletter article reports results of a survey that identified areas to focus on in revising the ISMP list of high-risk medications.