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Safety Target
Search results for "Human Factors Engineering"
- Human Factors Engineering
- Medication Reconciliation
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Journal Article > Commentary
Why 'Universal Precautions' are needed for medication lists.
Shane R. BMJ Qual Saf. 2016;25:731-732.
Despite the support for maintaining medication lists in electronic health records, these lists can contain and perpetuate errors. This commentary suggests that a set of standards are needed to ensure accuracy of electronic medication lists and reduce unnecessary or duplicate prescriptions in discharge instructions.
Journal Article > Commentary
Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.
Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.
This article discusses hospital compliance with National Patient Safety Goals regarding medication safety and describes strategies to improve anticoagulant administration safety.
Journal Article > Commentary
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:257-260.
This monthly selection includes reports of a near miss when using a medication-reconciliation form as an order sheet, epidural tubing mistakenly utilized for an intravenous medication, a topical medication given orally, and problems with monitoring temperatures of medication refrigerators.
Journal Article > Study
Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences.
Schwappach DLB, Pfeiffer Y, Taxis K. BMJ Open. 2016;6:e011394.
Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.
Book/Report
Meeting the Joint Commission's 2013 National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
This e-book provides tips for incorporating activities into daily hospital practice in conjunction with the 2013 National Patient Safety Goals.
Newspaper/Magazine Article
ISMP updates its list of drug name pairs with Tall man letters.
ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.
This article reports results of a national survey on how "tall man" lettering has clarified high-consequence drug name confusion and includes a list of medication name pairs in such lettering.
Journal Article > Commentary
Medication reconciliation in the emergency department: opportunities for workflow redesign.
Hummel J, Evans PC, Lee H. Qual Saf Health Care. 2010;19:531-535.
This article explains how to optimize medication reconciliation in the emergency department using a lean design method and discusses the role of patients and clerical staff in improving the medication information gathering process.
Journal Article > Commentary
The role of housestaff in implementing medication reconciliation on admission at an academic medical center.
Evans AS, Lazar EJ, Tiase VL, et al. Am J Med Qual. 2011;26:39-42.
This article details how one academic medical center engaged housestaff in tactics to achieve higher compliance with medication reconciliation.
Journal Article > Review
Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.
Semple SJ, Roughead EE. Aust New Zealand Health Policy. 2009;6:24.
This review completes a two-part study of medication error in Australia and provides an examination of approaches to build safe medication systems.
Journal Article > Commentary
2009 National Patient Safety Goals.
Saufl NM. J Perianesth Nurs. 2009;24:114-118.
This commentary provides background on the development of the Joint Commission's 2009 National Patient Safety Goals and summarizes the goals set for the hospital environment.
Cases & Commentaries
Double Dosing, by the Rules
- Web M&M
Hedy Cohen, RN, BSN, MS; February-March 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
Audiovisual
Vincristine: Learning from Error Workshop.
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.
Through a discussion of a vincristine administration error, this booklet and video illustrate how system weaknesses can contribute to failure.
Newspaper/Magazine Article
Medication errors associated with documented allergies.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Meeting/Conference > Government Resource
AHRQ 2007 Annual Conference.
Rockville, MD: Agency for Healthcare Research and Quality; August 2008.
This Web site provides access to presentation materials from AHRQ's first annual conference, held in September 2007.
Newspaper/Magazine Article
What drugs do you take? Hospitals seek to collect better data and prevent errors.
Landro L. Wall Street Journal (Eastern edition). May 23, 2006:D1. [reprinted on Post-Gazette.com]
This article discusses the shared responsibility among patients, hospitals, and practitioners to support appropriate drug administration through medication reconciliation.