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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.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
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.
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.
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.
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.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
ISMP Medication Safety Alert! Acute Care Edition. February 22, 2018;23:1-5.
Myriad system and clinician failures can contribute to medication errors. This newsletter article reviews factors that contribute to nebulized medication administration problems, such as unlabeled solutions, look-alike packaging, equipment misuse, and storage issues. Recommendations to reduce risks include team assessment of barcode scanning processes, communicating orders, and storing vials separately.
Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. PA-PSRS Patient Saf Advis. December 2017;14.
Near misses provide unique opportunities to identify and learn from safety hazards. Describing how one organization utilized data on near misses involving barcode medication administration over a 12-year period to reduce barcode-workflow events, this report outlines practices and strategies that contributed to success such as promoting event reporting and applying root cause analysis.
Quick Safety. October 16, 2017;(37):1-3.
ISMP Medication Safety Alert! Acute Care Edition. September 7, 2017;22:1-4.
Workflow processes for compounded sterile preparation can affect patient safety. Discussing how pharmacies have increasingly implemented workflow management systems to automate compounded sterile solution processes, this newsletter article reviews challenges associated with these systems and recommends strategies to reduce risks.
What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2016;21:1-3.
ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.
Patients and clinicians can make medication administration mistakes when new drug delivery mechanisms are introduced. This newsletter article reviews common errors associated with the use of inhalers and offers recommendations for patients, nurses, respiratory therapists, pharmacists, and health care organizations to educate patients on the use of these medications.
Eid KA. Nursing. 2015;45:14-16.
Robust processes that enable review and analysis of medical errors are critical to support organizational learning. This commentary highlights one institution's experience convening a multidisciplinary committee focused on improving medication administration through analysis of medication-related incidents and implementing interventions based on the group's findings.
ISMP Medication Safety Alert! Acute Care Edition. December 4, 2014;19:1-6. March 26, 2015;20:1-4.
This newsletter series reports on 2 years of data collected during a national effort to collect vaccine administration errors. The first article summarizes information about the types of vaccine errors reported and why they occur. The second article discusses risks during vaccine use and offers recommendations to prevent them.
Tavernise S. New York Times. January 15, 2015.
This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.
ISMP Medication Safety Alert! Acute Care Edition. June 5, 2014;19:1-2,4-5.
Written numbers and letters that look alike can contribute to miscommunication in a variety of settings. This newsletter article provides examples of this issue in medication administration, discusses factors that increase risks, and recommends tactics to avoid confusion.
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.