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Search results for "Human Factors Engineering"
Journal Article > Commentary
Goolsarran N, Martinez J, Garcia C. BMJ Open Qual. 2019;8:e000593.
Near misses can uncover process weaknesses and motivate improvement to prevent similar incidents. This commentary outlines how one hospital used Plan–Do–Study–Act cycles to improve their MRI screening process, including developing and implementing a safety checklist in the electronic medical record and building in a hard stop to prompt checking for contraindications.
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.
Journal Article > Study
Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.
Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.