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- Communication Improvement 1
- Education and Training 4
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events
- Nonsurgical Procedural Complications 1
Search results for "Medication Safety"
ISMP Medication Safety Alert! Acute Care Edition. May 22, 2014;19:1-2.
Errors occur frequently in vaccine administration when packaging instructions for diluents are unclear. This newsletter article offers recommendations for manufacturers and practitioners to reduce risks related to vaccines.
Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors.
ISMP Medication Safety Alert! Acute Care Edition. March 13, 2014;19:1-2,4-5.
Summarizing results from a national survey investigating vaccine administration errors, this article outlines recommendations to reduce risks associated with the use and packaging of vaccines. Tips include establishing protocols for commonly used vaccines, requiring periodic training for staff, and labeling prepared syringes.
Wright J. Nursing Times. 2013;109:11-14.
This record review study found that omitted doses of antimicrobial medications occur frequently in hospital settings in the United Kingdom.
Journal Article > Study
Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001–2011.
Guh AY, Thompson ND, Schaefer MK, Patel PR, Perz JF. Med Care. 2012;50:785-791.
This review documents 35 cases of unsafe injection practices in the United States over the past decade, leading to more than 100,000 patients being exposed to communicable diseases. In most cases, clinicians reused syringes or medication vials intended for single-dose usage. Although the authors ascribe these violations to failure to follow basic infection control practices, subsequent analysis of one widely publicized case also revealed that safety culture played a role, as nurses did not feel empowered to report improper injection practices due to fear of retaliation. The article also discusses the challenges of notifying patients about potential harm, and a recent Australian article describes the notification process used after a similar large-scale safety problem was identified.
Journal Article > Study
Pugliese G, Gosnell C, Bartley JM, Robinson S. Am J Infect Control. 2010;38:789-798.
This study surveyed more than 5000 providers who reported elements of unsafe injection practices, including use of single-dose/use vials for more than one patient, and reuse of syringes.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.
This alert notifies health care providers of the potential for patient harm if a particular inhalation powder is reconstituted and incorrectly administered.
Cases & Commentaries
- Web M&M
Michael Astion, MD, PhD; June 2004
Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment.