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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.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; August 29, 2006.
This news release announces a seizure of infusion pumps that have a "key bounce" defect that could result in over-infusion of medication.
ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.
This article describes problems involving the keys on infusion pumps and includes recommendations to help prevent errors when programming infusion pumps.
Patankar MS, Brown JP, Treadwell MD. Aldershot, UK: Ashgate Publishing; 2005. ISBN: 9780754642473.
The authors review the ethical foundations of safety in the aviation, health care, and occupational and environmental health industries. The authors encourage professionals to embrace ethical decision making in supporting their safety work.
Cases & Commentaries
- 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.
Journal Article > Commentary
Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.
Turakhia MP, Estes NA 3rd, Drew BJ, et al; Electrocardiography and Arrhythmias Committee of the American Heart Association Council on Clinical Cardiology and Council on Cardiovascular Nursing. Circulation. 2012;126:1665-1669.
This commentary details how the delay of electrocardiogram data distributed via wireless telemetry systems can affect patient safety and provides recommendations to prevent and mitigate such delays.
Journal Article > Study
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
Patient-controlled analgesia (PCA) is generally quite safe, but prior studies have shown that errors associated with PCA frequently result in patient harm. Due to several critical incidents associated with PCA errors, this Canadian hospital system implemented a multifaceted safety program including use of smart infusion pumps, standardized order sets, and mandatory error reporting. These interventions resulted in a significant reduction in PCA errors, chiefly by reducing pump programming errors (the most common type of error before the intervention). A PCA error with devastating clinical consequences is discussed in an AHRQ WebM&M commentary.