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ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.
This newsletter piece reviews smart infusion pump errors and makes recommendations to prevent them.
Cases & Commentaries
- Spotlight Case
- Web M&M
Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN; January 2016
Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.
Journal Article > Study
Patient-as-observer approach: an alternative method for hand hygiene auditing in an ambulatory care setting.
Le-Abuyen S, Ng J, Kim S, et al. Am J Infect Control. 2014;42:439-442.
In this quality improvement study, patients were asked to report on their physician's hand hygiene practice, and mirroring results of prior studies, most patients were willing to participate and rated their physicians highly. Patient reports and nurse observations regarding hand hygiene compliance corresponded 87% of the time, leading the authors to conclude that engaging patients in this role is a feasible method to promote compliance.
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.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Journal Article > Review
Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review.
Raban MZ, Westbrook JI. BMJ Qual Saf. 2014;23:414-421.
Interruptions are inevitable in the busy clinical environment and may contribute to preventable harm, particularly if they occur during medication administration. This systematic review attempted to synthesize research regarding the effectiveness of interventions that have been tested to limit interruptions during medication administration. These efforts included sterile cockpit approaches derived from the aviation industry. Although some interventions did reduce interruption rates, medication error rates were largely unaffected and the literature has significant methodological flaws. The authors caution that hospitals should not attempt to simply limit interruptions, because there is no clear evidence that doing so will prevent medication errors and some interruptions are necessary for patient care.
Journal Article > Study
Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis.
Coleman JJ, Hodson J, Brooks HL, Rosser D. Int J Qual Health Care. 2013;25:564-572.
Implementation of dashboards that displayed medication administration errors at the individual unit level was associated with a decline in the rate of missed medication doses at a British teaching hospital.
Journal Article > Commentary
Gavriloff C. J Pediatr Nurs. 2012;27:375-382.