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- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 2
Human Factors Engineering
- Medical Alarm Design
- Quality Improvement Strategies 1
- Specialization of Care 2
- Technologic Approaches 2
- Alert fatigue 1
- Device-related Complications 2
- Interruptions and distractions 1
- Medication Errors/Preventable Adverse Drug Events 4
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for "Medical Alarm Design"
- Medical Alarm Design
- Specific to High-Risk Drugs
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.
Journal Article > Study
Lester PE, Rios-Rojas L, Islam S, Fazzari MJ, Gomolin IH. Drugs Aging. 2015;32:227-233.
Older patients are particularly vulnerable to medication errors, with certain high-risk medications accounting for a large proportion of adverse drug events in these patients. This study evaluated the effect of warnings within a computerized provider order entry (CPOE) system targeting prescribing of unsafe medications to patients aged 65 years and older. The warnings resulted in a significant decrease in prescribing of two of the three medications targeted over a 3-year period. The authors note that there were readily available, safer alternatives for those medications, but not for the drug which continued to be prescribed. Also, prescription rates of all three medications were unchanged in younger patients, indicating that the tailored nature of the alerts played a role in their effectiveness. While clinical decision support within CPOE does have some effect on safe prescribing, the use of computerized warnings of this type must be balanced against the very real possibility that alert fatigue may develop as a result.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.
This article provides screening, dosing, and monitoring recommendations for using basal opioid infusions and patient-controlled analgesia (PCA) in patients at risk for developing respiratory depression.
Audiovisual > Audiovisual Presentation
Opioid-Induced Ventilatory Impairment (OIVI): Time for Change in the Monitoring Strategy for Postoperative PCA Patients.
Anesthesia Patient Safety Foundation. February 2014.
This video highlights a need for improved electronic monitoring of post-operative patients receiving opioids and includes footage from a multidisciplinary conference that offered patient experiences and expert insights about opioid safety.
Perspectives on Safety > Perspective
with commentary by Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN, Bar Coding for Medication Safety, September 2008
Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.
In: On the State of the Public Health: Annual Report of the Chief Medical Officer 2004. London, England: Department of Health; 2005.
This chapter analyzes compliance with National Health Service patient safety alerts, as outlined in An Organization with a Memory, in four risk areas and makes recommendations for improving compliance.