Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 2
- Education and Training 1
- Human Factors Engineering 1
- Quality Improvement Strategies 2
- Technologic Approaches 3
Search results for "Medication Safety"
Cases & Commentaries
- Web M&M
Audrey Lyndon, PhD, RN, and Stephanie Lim, MD; June 2019
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
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.
Journal Article > Study
Improving documentation of a beta-blocker quality measure through an anesthesia information management system and real-time notification of documentation errors.
Nair BG, Peterson GN, Newman S, Wu W, Kolios-Morris V, Schwid HA. Jt Comm J Qual Patient Saf. 2012:38;283-288.
Journal Article > Study
Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.
Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.
A comprehensive quality improvement intervention resulted in a significant reduction in adverse drug events due to opioid pain medications, particularly in the immediate postoperative period.
Ellis K. Surgicenteronline.com [serial online]. May 1, 2006.
This article discusses the application of several Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goals in ambulatory surgery centers (ASCs) and interviews one practitioner about implementing patient safety interventions in his ASC.