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Search results for "Hospitals"

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Journal Article > Study

Accidents and incidents related to intravenous drug administration: a pre-post study following implementation of smart pumps in a teaching hospital.

Guérin A, Tourel J, Delage E, et al. Drug Saf. 2015;38:729-736.

This pre-post study evaluated the impact of smart pump infusion devices on reported adverse drug events (ADEs) in an inpatient setting. Researchers observed an increase in ADEs immediately following implementation of the new devices, as has been previously seen after electronic health record implementation. Subsequently, ADEs returned to rates similar to before smart pump use. This lack of benefit from smart pumps indicates the need for human factors approaches to characterize the actual use of devices.

Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Journal Article > Commentary

Medication safety in the neonatal intensive care unit: big measures for our smallest patients.

Rostas SE. J Perinat Neonatal Nurs. 2017;31:15-19.

Medication errors are common in the neonatal intensive care unit. This commentary outlines various strategies one teaching hospital has utilized to reduce risks of medication errors in this care setting, such as use of computerized provider order entry and smart pumps.

Journal Article > Commentary

Using computerized prescriber order entry to limit overrides from automated dispensing cabinets.

Drake E, Srinivas P, Trujillo T. Am J Health Syst Pharm. 2016;73:1033-1035.

Automated dispensing cabinets have been adopted in hospitals to enhance medication safety. These drug dispensing systems enable override functions so that nurses can access medications without pharmacist verification to ensure timeliness, but this workaround requires a reliable process to reduce the potential for errors. This commentary discusses how one hospital designed an oversight process using computerized provider order entry to increase the safety of this practice.

Journal Article > Study

Risk factors for i.v. compounding errors when using an automated workflow management system.

Deng Y, Lin AC, Hingl J, et al. Am J Health Syst Pharm. 2016;73:887-893.

Mistakes during preparation of intravenous (IV) medications can lead to dosing errors and adverse drug events. Analyzing data collected over 12 months in a hospital's automated IV compounding workflow management system, this study found that IV compounding errors occurred in less than 1% of cases and were usually intercepted through the automated system. These results suggest that existing processes do support safe medication use.

Journal Article > Study

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

Schnock KO, Dykes PC, Albert J, et al. BMJ Qual Saf. 2017;26:131-140.

Medication errors associated with intravenous smart pumps are a safety concern. Because errors are not always reported, the magnitude of this problem has been unknown. In this study, direct observation of nurses using smart pumps revealed that 60% of medication infusions involved one or more errors, but actual harm to patients was rare. The most common errors involved incorrect infusion rates and workarounds like bypassing the smart pump. These results accentuate a need for improvements in smart pump design to enhance safety and usability. A previous WebM&M commentary describes consequences of an incorrect medication infusion.

Cases & Commentaries

Hyperglycemia and Switching to Subcutaneous Insulin

  • Web M&M

Tosha Wetterneck, MD, MS; December 2015

Hospitalized with nonketotic hyperglycemia, a man was placed on IV insulin and his blood sugars improved. That evening, the patient was transferred to the ICU with chest pain and his IV insulin order was changed to sliding scale subcutaneous insulin. However, over the next several hours, the patient again developed hyperglycemia.

Journal Article > Study

Impact of automated dispensing cabinets on medication selection and preparation error rates in an emergency department: a prospective and direct observational before-and-after study.

Fanning L, Jones N, Manias E. J Eval Clin Pract. 2016;22:156-163.

Adverse drug events continue to contribute to preventable errors for both hospitalized and ambulatory patients. In this study conducted in an Australian emergency department, implementation of automated dispensing cabinets for frequently used medications was associated with a decrease in medication preparation and dispensing errors by nurses.

Journal Article > Commentary

Maximizing smart pump technology to enhance patient safety.

Makic MBF. Clin Nurs Spec. 2015;29:195-197.

Smart pumps are considered a valuable method to improve medication safety. However, users may engage in workarounds that bypass the safety features of the equipment. This commentary relates risks and benefits associated with smart pumps and highlights opportunities to augment adoption and use of smart pump technology to prevent medication errors. A past AHRQ WebM&M perspective describes the value of smart pump technologies as a medication safety strategy.

Journal Article > Study

Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center.

Rochais E, Atkinson S, Guilbeault M, Bussières JF. J Pharm Pract. 2014;27:150-157.

Nurses felt that the introduction of automated dispensing cabinets improved medication safety and made their work easier.

Journal Article > Study

Errors during the preparation of drug infusions: a randomized controlled trial.

Adapa RM, Mani V, Murray LJ, et al. Br J Anaesth. 2012;109:729-734.

Medication errors were less frequent and medications were administered more rapidly, when pre-filled syringes were used instead of the traditional method of preparing intravenous infusions at the bedside.

Cases & Commentaries

Double Dose at Transfer

  • Web M&M

Jeffrey L. Hackman, MD; May 2012

Diagnosed with cellulitis, an elderly man was admitted to the hospital after receiving the first dose of vancomycin in the ED. Just 3 hours later, a floor nurse noted the admission order for vancomycin every 12 hours and administered another dose.

Journal Article > Commentary

Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project.

Harding AD. Am J Nurs. 2012;112:26-35. 

This commentary details how one hospital successfully increased use of smart pumps to improve medication safety.

Newspaper/Magazine Article

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

This news article reviews actual and potential medication errors submitted to the Institute for Safe Medication Practices in 2010 and provides recommendations to address them.

Journal Article > Study

Prevalence of medication administration errors in two medical units with automated prescription and dispensing.

Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-78.

Technological solutions such as computerized provider order entry (CPOE) hold promise for reducing medication errors at the prescribing and dispensing stage, but patients may still be harmed by incorrect administration of medications, which have been shown to be disturbingly common in prior studies. Conducted at an academic hospital in Spain that had an established CPOE system, this study found an overall administration error rate of 22%, consistent with prior studies. The hospital in question did not have a barcoding medication administration system. Combining barcoding with CPOE in a closed-loop system has been shown to significantly reduce the overall medication error rate.

Newspaper/Magazine Article

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

This piece identifies situations in which patient verification errors occur and provides strategies to address them.

Newspaper/Magazine Article

Guidelines for timely medication administration: response to the CMS "30-minute rule."

ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.

This article reports results from a survey on the Centers for Medicare & Medicaid Services "30-minute rule" and provides a set of revised guidelines.

Journal Article > Study

Automated drug dispensing system reduces medication errors in an intensive care setting.

Chapuis C, Roustit M, Bal G, et al. Crit Care Med. 2010;38:2275-2281.

An automated drug dispensing system reduced medication errors at both the dispensing and administration steps in an adult intensive care unit.

Newspaper/Magazine Article

CMS 30-minute rule for drug administration needs revision.

ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.

This piece highlights nurses' responses to a national survey that explored problems associated with the Centers for Medicare and Medicaid Services (CMS) medication administration timing requirement.

Journal Article > Study

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals.

Wakefield DS, Ward MM, Loes JL, O'Brien J. J Am Med Inform Assoc. 2010;17:584-587.

Uptake of health information technology has been slow, especially in smaller hospitals and ambulatory practices. This article describes the successful implementation of an electronic medical record in a group of rural and critical access hospitals.

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