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- Communication Improvement 1
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 7
Quality Improvement Strategies
- Practice Guidelines
- Technologic Approaches 1
Search results for "Practice Guidelines"
- Infusion Pumps
- Practice Guidelines
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.
ISMP Medication Safety Alert! Acute Care Edition. August 23, 2007;12:1-3.
This article discusses the myriad dosing methods that can lead to errors in administering intravenous medications and programming infusion pumps.
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. April 6, 2006;11:1-2.
This article outlines systems failures that can contribute to the inadvertent misadministration of IV medications and provides several recommendations to support safe practices.
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.
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.
Cases & Commentaries
- Web M&M
Curtiss B. Cook, MD; January 2009
Admitted to the hospital for surgery, a man with type 1 diabetes mellitus asked the staff to leave his home insulin pump in place but did not mention that he was adjusting his insulin pump himself based on serial glucose measurements. As the patient was also receiving an intravenous insulin infusion, he developed hypoglycemia.
Food and Drug Administration (FDA) Patient Safety News. Show #57. November 2006.
This video news segment recaps concerns over the use of an infusion pump with an identified design defect.
Journal Article > Commentary
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].
Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.
The authors provide a case study involving patient-controlled analgesia (PCA) pump errors that contributed to an accidental morphine overdose. They discuss how the case illustrates that small mistakes can combine to create major problems.