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- Communication Improvement 1
- Culture of Safety 1
- Human Factors Engineering 3
- Logistical Approaches 1
- Policies and Operations 1
- Quality Improvement Strategies 1
- Technologic Approaches 7
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medication Errors/Preventable Adverse Drug Events 4
- Surgical Complications 1
Search results for "Information Professionals"
Clark R. Health Manage Tech. July 2006:18, 20-21.
The author discusses five aspects to consider in adopting perioperative information technologies: system integration, fault tolerance, accessibility, workflow support, and measurable results.
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.
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.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
This article analyzes a fatal error involving parenteral nutrition and makes recommendations to prevent such incidents.
Kuehn BM. JAMA. 2009;301:919-920.
In the context of the Obama administration's efforts to computerize medical records, this news story describes problems and errors that have occurred with the electronic medical records systems in Veterans Affairs hospitals.
Health Management Technology. August 2005;26:24,26-27.
This case study presents a Louisiana hospital's experience in implementing a bedside bar-coding system.