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Search results for "North America"
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.
Wiley F. Drug Topics. August 2019;1633:16-18.
High-alert medications have the potential to cause serious patient harm if not administered correctly. Reporting on challenges to medication safety in the context of home, hospital, and cancer care, this news article recommends patient and health care professional education and support for collaboration with pharmacists as avenues for improvement.
Partnering with families and patient advocates: another line of defense in adverse event surveillance.
ISMP Medication Safety Alert! Acute Care Edition. August 1, 2019;24.
Having family members or patient advocates present during hospitalizations can help prevent errors. This newsletter article suggests that utilizing this risk prevention strategy in peripheral care areas such as radiology and other testing units could also prevent patient harm. Recommendations to ensure success of this approach include communicating with advocates, encouraging them to speak up, and activating a rapid response to patient deterioration.
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
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.
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.
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.
Dembosky A. All Things Considered and KQED. January 23, 2019.
Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.
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.
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
Look-alike and sound-alike medications present a recurring threat to patient safety. This newsletter article summarizes an analysis of reported drug name confusion errors. Although incidents seem to have decreased over time, the influx of generic drug names is contributing to the persistence of the problem. Increased federal attention to the issue, provider use of known strategies to improve practice, and pharmaceutical company testing of names to avoid similarities can help reduce drug name confusion.
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.
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.
Sederstrom J. Drug Topics. September 17, 2018.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.
ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.
Mistakes in the use of vaccines can have both individual and public health implications. The first article of this series reviews the results from an analysis of reports submitted to a national error reporting system to track vaccine-related errors. The second article offers recommendations to help immunization and vaccination programs address product-, knowledge-, and practice-related factors that contribute to process weaknesses, including training, storage, and labeling strategies.
Kowalczyk L. Boston Globe. May 27, 2018.
Pediatric patients are particularly vulnerable to medication errors. This news article reports on serious medication errors that occurred at Children's Hospital in 2017, the underlying system failures that contributed to the incidents, and challenges to implementing new policies meant to prevent similar errors.
Porter S. HealthLeaders Media. April 26, 2018.
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medication overdose that led to the death of a patient with dementia, this news article describes how the hospital changed their processes to improve medication safety, which included restructuring medication safety leadership, modifying the electronic health record to address alert overrides, and enhancing information sharing to support learning and transparency.
Pharmacy Practice News. April 4, 2018.
Despite considerable effort, medication errors continue to occur and result in patient harm. Summarizing reports of medication mistakes submitted to the Institute for Safe Medication Practices for analysis, this news article describes types of problems, prevention strategies, and technologies that can reduce risks.