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Communication between Providers
- Sbar 1
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Human Factors Engineering
- Checklists 44
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- Quality Improvement Strategies 44
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- Discontinuities, Gaps, and Hand-Off Problems 11
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- Identification Errors 10
- Interruptions and distractions 9
- Medical Complications 24
- Medication Errors/Preventable Adverse Drug Events 83
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Health Care Providers
- Nurses 21
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Non-Health Care Professionals
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Search results for "Human Factors Engineering"
- Newspaper/Magazine Article
- Human Factors Engineering
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.
Erich J. EMS World. April 2019;48:26-31.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
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.
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.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
Vosper H, Lim R, Knight C, Bowie P, Edwards B, Hignett S; CIEHF Pharmaceutical Human Factors Special Interest Group. Clinical Pharmacist. 2018;10(2).
Traditionally, efforts to reduce medical errors have focused on modifying individual behavior rather than systems. This article reviews the use of systems thinking models to address failure and discusses how small problems can combine into organizational failure. The authors suggest that the health care workforce develop human factors engineering competencies to achieve improvements.
Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.
Kuang C. Fast Company. October 4, 2017.
Complicated systems often require more than one change to improve their safety. Poor patient understanding of prescription labels and medication dispensing processes at retail pharmacies contribute to medication errors. This news article discusses a strategy that began with color-coded labels and led to a retail pharmacy implementing redesigned pill bottles that provide an overall prescription regimen.
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for psychiatric patients must make unique considerations to protect this vulnerable population from harming themselves and other individuals that come into contact with them. This magazine article provides recommendations for hospitals to enhance room and fixture designs to reduce risks for mental health patients.
Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2016;21:1-4.
Insulin is a high-alert drug, and its use is becoming more complex due to the insulin resistance in diabetic patients with obesity. This newsletter article describes the experience of one hospital system that worked to ensure safe insulin administration by implementing a strategy that combined single-use pens and health information technology.
Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.
ISMP Medication Safety Alert! Acute Care Edition. February 25, 2016;21:1-5.
From a human error perspective, the suggestion to be more careful is not a reliable safety strategy. Discussing weaknesses associated with this approach as a way to improve vaccine safety, this newsletter article provides recommendations focused on addressing system and human factors to reduce errors related to two-component vaccines.
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
The disabling of alerts due to alarm fatigue can hinder the ability of a health information system to warn prescribers and pharmacists of potentially harmful drug–disease combinations. This newsletter article describes an incident in which a patient died when health information technology systems failed to alert the physician and pharmacist regarding a drug–disease interaction. Recommendations to avoid risks include evaluating drug information databases, adding comorbid conditions into electronic health records, and reducing provider overreliance on alerts.
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.
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.
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.
Kenler AS. Patient Saf Qual Healthc. July/August 2012;9:40-42.
This article discusses concerns with the diagnostic testing process and recommends that time outs can reduce risks.
Nurs Stand. Apr-May 2012;26.
This series explores how nurses can use human factors to enhance safety in their daily practice.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.
This newsletter piece reviews smart infusion pump errors and makes recommendations to prevent them.