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Search results for "Hospitals"

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Book/Report

Guidelines for Adult IV Push Medications.

Horsham, PA: The Institute for Safe Medication Practices; July 2015.

To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.

Journal Article > Study

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

Pronovost P, Holzmueller CG, Needham DM, et al. Crit Care Med. 2006;34:1988-95.

This study provides an evaluative framework for addressing whether our health care system is safer compared to years past. The authors discuss a measurement approach that focuses on the following: how often do we harm patients, how often do patients receive the appropriate interventions, how do we know we learned from defects, and how well have we created a culture of safety. Building on a model of structure, process, and outcome measures used to evaluate health care quality, the authors present a detailed discussion of attributes necessary for safety-specific measures. They provide a case-type example of their suggested process to illustrate their framework. Reflecting on the 5 years since release of the IOM report, past commentaries by Leape and Berwick as well as Wachter focused on progress in patient safety and provide further context to the efforts of this study.

Clinical Guideline

Guideline for opioid therapy and chronic noncancer pain.

Busse JW, Craigie S, Juurlink DN, et al. CMAJ. 2017;189:E659-E666.

Opioid pain medications carry high risk for adverse drug events, and opioid misuse is a growing patient safety concern. This guideline provides recommendations to augment safe prescribing of these high-risk medications for patients with chronic noncancer pain.

Clinical Guideline

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.

Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. JAMA Surg. 2017 May 3; [Epub ahead of print].

Surgical site infections are a common hospital-acquired condition. This clinical guideline reviews the literature and gathers expert opinion to identify generalizable evidence-based strategies to reduce surgical site infections. The authors highlight antimicrobial, preoperative hygiene, glycemic control, and skin preparation procedures to prevent infection.

Cases & Commentaries

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Cases & Commentaries

The Empty Bag

  • Web M&M

Chris Vincent, PhD; December 2016

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

Legislation/Regulation > Multi-use Website

National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; 2017.

The National Patient Safety Goals (NPSGs) have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety. The criteria used for determining the value of these goals, and required revisions to them, are based on the merit of their impact, cost, and effectiveness. Recent changes have focused on preventing hospital-acquired infections and medication errors, in addition to existing goals promoting surgical safety, correct patient identification, communication between staff, and identifying patients at risk for suicide. In 2014, the group added improving the safety of hospital alarm systems, with a plan for a phased implementation of performance measures. For 2017, a new NPSG on catheter-associated urinary tract infections (CAUTI) will apply to nursing care centers, and the NPSGs on CAUTIs for hospitals and critical access hospitals have been revised to apply current evidence.

Journal Article > Study

Evidence-based guidelines for fatigue risk management in EMS: formulating research questions and selecting outcomes.

Patterson PD, Higgins JS, Lang ES, et al. Prehosp Emerg Care. 2016 Nov 18; [Epub ahead of print].

The impact of fatigue on clinician performance is a concern across health care settings. This study explained how researchers developed key questions to help assess fatigue in prehospital emergency medical services. They describe a plan to conduct systematic reviews to inform future guidelines.

Journal Article > Commentary

ASPEN Safe Practices for Enteral Nutrition Therapy.

Boullata JI, Carrera AL, Harvey L, et al; ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2017;41:15-103.

Enteral nutrition is provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead to safety hazards. Drawing from current evidence, these consensus guidelines recommend best practices to ensure safety of enteral nutrition, including a six-step standardized approach to administering eternal nutrition that involves independent double-checks and automation with forcing functions.

Book/Report

Global Guidelines on the Prevention of Surgical Site Infection.

Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.

Journal Article > Commentary

Making the journey safe: recognising and responding to severe sepsis in accident and emergency.

Pinnington S, Atterton B, Ingleby S. BMJ Qual Improv Rep. 2016;5:u210706.w4335.

The early recognition of sepsis is crucial to safe and effective treatment. This commentary discusses an intervention that used tools to determine barriers and hazards to sepsis management in emergency care. The tools helped identify and prioritize process points for targeted improvement and track the impact of the changes over time. A previous WebM&M commentary discussed best practices to reduce sepsis-related mortality.

Book/Report

ISMP Guidelines for Safe Preparation of Compounded Sterile Preparations.

Horsham, PA: Institute for Safe Medication Practices; 2016.

This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety.

Web Resource > Multi-use Website

Indiana Patient Safety Center.

Indiana Hospital Association.

Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and reliable systems of care in the state. This website provides resources related to IPSC educational activities and efforts to raise awareness of local and national safety initiatives, including the Hospital Engagement Network.

Newspaper/Magazine Article

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.

If cost-saving decisions are made without adequate consideration, they can increase risks. This newsletter article raises awareness that alternative epinephrine administration methods used to reduce device costs can introduce heightened potential for dosing errors and lead to serious patient harm.

Book/Report

Avoiding Unconscious Bias: a Guide for Surgeons.

London, UK: Royal College of Surgeons of England; 2016.

Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.

Journal Article > Study

Safety of the Manchester Triage System to detect critically ill children at the emergency department.

Zachariasse JM, Kuiper JW, de Hoog M, Moll HA, van Veen M. J Pediatr. 2016;177:232-237.

Emergency department triage systems are designed to prioritize patients based on the level of illness. Inappropriate triage can lead to delays in care and adverse events. In Europe, the Manchester Triage System is a widely used algorithm that classifies patients based on five levels of urgency with a corresponding maximum waiting time. This study sought to assess the effectiveness of the Manchester Triage System in children requiring admission to the intensive care unit (ICU). Analyzing more than 50,000 consecutive emergency department visits of children younger than 16, the authors determined that almost one third of children admitted to the ICU were undertriaged. Risk factors identified for undertriage included age younger than 3 months, type of medical presenting problem, presence of underlying chronic conditions, referral by a specialist or emergency medical services, and arrival during the evening or at night. These findings suggest that the Manchester Triage System inappropriately triages a significant proportion of children requiring ICU admission and that modifications should be made to improve safety in pediatric emergency care. A previous WebM&M commentary discussed the challenges of triage in the emergency department.

Journal Article > Commentary

Guideline implementation: prevention of retained surgical items.

Fencl JL. AORN J. 2016;104:37-48.

Although incidents involving retained surgical items are rare, they continue to occur. This commentary reviews guidance for perioperative nurses to reduce risks of this sentinel event. The author outlines steps to improve safety such as team accountability, standardized surgical sponge counts, and reconciling count discrepancies.

Special or Theme Issue

Mistakes We Make in Dialysis.

Rodby RA, Perazella MA, eds. Semin Dial. 2016;29:253-328.

Insufficient application of new evidence to inform treatment decisions can hinder safe care delivery. Articles in this special issue explore common renal replacement management strategies that may need to be assessed and redesigned to improve the safety of patients receiving dialysis.

Book/Report

A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2016.

Learning organizations are capable of addressing problems through information sharing and learning from past experience to facilitate improvement and innovation. Large system failure occurs when such interventions are not disseminated and implemented. This report discusses the need to ensure that lessons learned in military trauma care are acted on and sustained and recommends that this information be translated for the civilian health system as a way to reduce preventable patient harm in trauma care.

Newspaper/Magazine Article

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6.

Neuromuscular blockers can result in serious harm if administered incorrectly. This newsletter article reports the types of errors associated with the use of these high-alert medications, such as look-alike and sound-alike problems that lead to the wrong drug being administered. Recommended strategies to reduce risks include use of standardized prescribing and smart pump technologies.

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