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ISMP Medication Safety Alert! Acute Care Edition. August 29, 2019;24.
Mistakes in the administration of intravenous (IV) medications can result in patient harm. Analyzing data from 243 health care facilities regarding the quality of IV push practices in the field, this newsletter article reports adoption of practices such as the use of a new syringe and needle for every IV push injection and outlines 10 best practices to consider for improvement, including the routine supply of IV push medications in ready-to-administer containers and reporting to external bodies to enhance learning.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
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.
Decerbo M. Pharmacy Practice News. September 13, 2018.
Parenteral nutrition errors can result in patient malnutrition and harm. Reporting on how insufficient understanding of malnutrition contributes to its presence in health care, this news article suggests that both general guidelines and tailored approaches to nutrition are necessary to keep hospitalized patients safe. Improvements in addressing the complicated needs of patients who are older or have cancer illustrate progress made toward the effective delivery of nutrition.
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
Benchmarks tracking a wide spectrum of care activities enable comparison that can drive organizational commitment to improving safety. This newsletter article examines survey responses from nearly 400 hospitals which demonstrated modest progress in implementation of medication safety best practices that recommended strategies to augment safety, such as utilizing metric units as the only scale of measure for patient weight.
ISMP Medication Safety Alert! Acute Care Edition. January 15, 2015;20:1-4.
Wild D. Pharmacy Practice News. September 8, 2014.
Highlighting how hospital compliance rates with Joint Commission medication–related standards have remained mostly unchanged from 2012 to 2013, this article provides information about the most problematic areas identified—medication storage, drug orders, pharmacist review, labeling, and medication reconciliation—along with ways to address them.
PA-PSRS Patient Saf Advis. March 2012;9:11-17.
This newsletter article discusses data on medication errors that occurred when pharmacy departments were closed and provides strategies to prevent such incidents.
PA-PSRS Patient Saf Advis. March 2011;8:1-7.
This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvement as a strategy to reduce risks.
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2009;14:1-4.
This article shares insights and recommendations regarding using the ISMP guidelines for automated dispensing cabinets.
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
This article describes errors associated with bar coded medication administration and provides strategies to avoid mistakes that stem from workarounds and overrides, disruptions in the medication administration process, and pharmacy dispensing errors.
PA-PSRS Patient Saf Advis. May 2007;4(suppl 2):1-8.
This article shares findings from a workgroup that assessed the efficacy of pharmacy computer systems in detecting unsafe medication orders. The 30 Pennsylvania hospitals that participated in the workgroup found that their systems were not catching all unsafe orders.