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Search results for "Nurse Managers"

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Journal Article > Study

Examining the relationship among ambulatory surgical settings work environment, nurses' characteristics, and medication errors reporting.

Farag AA, Anthony MK. J Perianesth Nurs. 2015;30:492-503.

This survey study of nurses across four ambulatory surgical wards in Ohio found that nursing managers' leadership styles and some aspects of the safety climate (such as teamwork and organizational learning) were associated with how willing nurses are to report medication errors.

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.

Journal Article > Review

Medication communication: a concept analysis.

Manias E. J Adv Nurs. 2010;66:933-943.

This article reviews aspects of medication communication and how it affects medication use, adherence, and adverse events. The authors specifically discuss how the concepts presented apply to nursing.

Press Release/Announcement

2007 Study of Injectable Medication Errors.

Silver Spring, MD: American Nurses Association; June 18, 2007.

The American Nurses Association announces the results from a survey of more than 1000 nurses on medication error and syringe safety.

Cases & Commentaries

Workaround Error

  • Web M&M

Tess Pape, PhD, RN, CNOR; February 2006

Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.

Journal Article > Commentary

Using OrgAhead, a computational modeling program, to improve patient care unit safety and quality outcomes.

Effken JA, Brewer BB, Patil A, Lamb GS, Verran JA, Carley K. Int J Med Inform. 2005;74:605-613.

The authors describe their experience using a computerized model to understand the impact of organizational, patient unit, and patient characteristics on safety and quality. This study was supported with a grant from the Agency for Healthcare Research and Quality (AHRQ).

Journal Article > Study

Findings from the ISMP Medication Safety Self-Assessment for hospitals.

Smetzer JL, Vaida AJ, Cohen MR, Tranum D, Pittman MA, Armstrong CW. Jt Comm J Qual Saf. 2003;29:586-597.

This article reports the results of the first national survey of mediation safety readiness in hospitals, which identified a wide range of opportunities for improvement.

Meeting/Conference > New Jersey Meeting/Conference

ISMP Medication Safety Intensive.

Institute for Safe Medication Practices. September 21-22, 2017, Maggiano's Little Italy Hackensack, Hackensack, NJ.

This workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Journal Article > Study

Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions?

Byrne C, Sierra H, Tolhurst R. Br J Nurs. 2017;26:464-467.

Checklists can improve patient safety across multiple settings. This pre–post study found that use of a checklist to help nurses dispense medications upon hospital discharge led to a reduction in errors in discharge prescriptions.

Journal Article > Study

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting.

Garcia BH, Elenjord R, Bjornstad C, Halvorsen KH, Hortemo S, Madsen S. BMJ Qual Saf. 2017 Apr 21; [Epub ahead of print].

Look-alike and sound-alike medications can be erroneously substituted for each other, leading to adverse drug events. Use of nonproprietary medication names can prevent look-alike and sound-alike errors. In this simulation study, investigators compared how nurses handle medication packages with a prominent nonproprietary name versus standard medication packages. Participants prepared medications with nonproprietary labeling more quickly, but errors were rare across all packaging types.

Journal Article > Study

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. BMJ Qual Saf. 2017 Feb 23; [Epub ahead of print].

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Journal Article > Commentary

Opioids for pain management in older adults: strategies for safe prescribing.

Davies PS. Nurse Pract. 2017;42:20-26.

Use of opioids for pain management in older adults can contribute to various problems, including fall-related injury and delirium. This commentary discusses the role of nurse practitioners as prescribers of opioids and offers practice recommendations to reduce risks.

Journal Article > Commentary

Medication governance: preventing errors and promoting patient safety.

Kavanagh C. Br J Nurs. 2017;26:159-165.

Medication errors are a significant challenge to patient safety. Discussing various factors that weaken the medication administration process, this commentary highlights collaboration, safety culture, and curriculum development as tactics to enhance the role of nurses and nurse educators in improving medication safety.

Journal Article > Study

Do leadership style, unit climate, and safety climate contribute to safe medication practices?

Farag A, Tullai-McGuinness S, Anthony MK, Burant C. J Nurs Adm. 2017;47:8-15.

This cross-sectional survey study found an association between nurses' perceptions of leadership and their responses to the AHRQ Hospital Survey on Patient Safety Culture. Nurses' responses about a nonpunitive response to error were associated with their willingness to report medication errors. The authors suggest that safety culture is necessary but not sufficient to support medication safety.

Journal Article > Commentary

Teaching students to administer medications safely.

Koharchik L, Flavin PM. Am J Nurs. 2017;117:62-66.

Students are likely to make mistakes as they develop medication administration competencies. This commentary describes strategies to teach nursing students safe medication practices, including mathematical skill development and small group training.

Journal Article > Study

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. J Patient Saf. 2016 Dec 21; [Epub ahead of print].

Interruptions are known to contribute to medication administration errors. This pre–post study found that nurses experienced fewer interruptions and made fewer medication errors following the introduction of a separate medication room. These results demonstrate how changing the work environment can promote safety.

Journal Article > Commentary

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology.

Neuss MN, Gilmore TR, Belderson KM, et al. J Oncol Pract. 2016;12:1262-1271.

Administration errors involving chemotherapeutic agents can result in patient harm. This set of standards provides guidance to help ensure reliable use of these high-alert medications for both adult and pediatric patients. Components of the revised standards are expanded to include two-person verification, vinca alkaloid mini-bag administration, and labeling enhancements for home-based chemotherapy.

Journal Article > Study

Sources and magnitude of error in preparing morphine infusions for nurse–patient controlled analgesia in a UK paediatric hospital.

Rashed AN, Tomlin S, Aguado V, Forbes B, Whittlesea C. Int J Clin Pharm. 2016;38:1069-1074.

Pediatric medication errors are common. In this study, researchers observed 153 nurse preparations of morphine infusions for pediatric patients and found significant variation in technique, which led to many patients receiving doses higher or lower than what was initially ordered.

Journal Article > Study

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

Armstrong GE, Dietrich M, Norman L, Barnsteiner J, Mion L. J Nurs Care Qual. 2017;32:226-233.

Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.

Tools/Toolkit > Fact Sheet/FAQs

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

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

Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.

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