Search results for "United States of America"

The National Patient Safety Goals (NPSGs) have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety. The criteria used for determining the value of these goals, and required revisions to them, are based on the merit of their impact, cost, and effectiveness. Recent changes have focused on preventing hospital-acquired infections and medication errors, in addition to existing goals promoting surgical safety, correct patient identification, communication between staff, and identifying patients at risk for suicide. In 2014, the group added improving the safety of hospital alarm systems, with a plan for a phased implementation of performance measures. For 2017, a new NPSG on catheter-associated urinary tract infections (CAUTI) will apply to nursing care centers, and the NPSGs on CAUTIs for hospitals and critical access hospitals have been revised to apply current evidence.

Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.

This observational study compared error detection rates for medication transcription errors between a hospital's formal reporting system and a passive error identification mechanism embedded in ordering software. As with prior studies of incident reporting systems, the formal reporting mechanism identified fewer errors than electronic surveillance, emphasizing the need to build error detection into technology platforms.

In this study, a hospital policy that allowed registered dieticians to directly enter physician cosigned diet orders for patients significantly decreased nutrition-related error rates and time delays.

This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.

Warfarin and other anticoagulant medications place patients, especially elderly ones, at high risk of adverse drug events (ADEs) due to their narrow therapeutic window. This retrospective analysis of anticoagulant-related ADEs at an academic medical center identified the underlying cause of these events and found evidence that a large proportion should be preventable. More than two-thirds of anticoagulant-related ADEs were attributable to medication errors, usually at the medication administration stage. A large proportion of the errors were ascribed to incorrect transcription of orders. The persistent incidence of transcription errors in this study is especially surprising given that the hospital in question already had a computerized provider order entry (CPOE) system. Fully electronic closed-loop medication systems, which integrate CPOE, barcoding, and electronic medication administration records, hold promise as a means of reducing both transcribing and administration errors.

Information technology solutions have proven effective at reducing some types of medication errors. For example, computerized provider order entry (CPOE) can reduce errors at the prescribing and transcription stages. Bar-coding of medications has been advocated as a means of reducing medication administration errors; although some studies have found success, others have noted unintended consequences. This study tested a "closed-loop" system that combined CPOE, bar-coding, and an electronic medication administration record (eMAR) in an academic medical center, and found that the system significantly reduced administration errors as well as potential adverse drug events. The authors note that significant changes in workflow were necessary to achieve these results and caution that successful use of this technology requires considerable attention to development and implementation.

This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers.

This study discovered variability in pharmacists' interpretation of physician prescriptions, raising concerns about the consistency of information provided to patients about safe medication use.

The American Society of Health-System Pharmacists (ASHP) offers policy positions, statements, and guidelines to ensure safe inpatient medication administration. This study highlights their findings from a survey of more than 1200 pharmacy directors across the country. Major trends identified since past administrations of the same survey include a gradual decline in use of the formulary system, an increase in the use of clinical practice guidelines, a growth in methods to improve prescribing practices, and rapid changes in practice driven by accreditation standards. The authors conclude that pharmacists are responding to changes in the health care system and driving efforts to improve medication use.

Avoiding use of unclear or misleading abbreviations is a key step in preventing medication prescribing errors, and the Joint Commission mandates avoiding specific abbreviations as one of its National Patient Safety Goals. This study analyzed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's ''do not use'' abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.

This article describes how electronic prescribing can help reduce miscommunication and improve safety, although its universal adoption faces numerous barriers.

This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values.

This guidance statement recommends minimal requirements for eliminating the use of "do-not-use" items in the perioperative environment.

The authors describe the development of a collaborative model to reduce physician use of dangerous abbreviations and discuss its successful implementation and positive outcomes.

This monthly selection of medication error reports provides examples of problems related to poorly scanned pharmacy orders, ambiguous labeling, and abbreviation use.

This news release announces the governor's plans to improve patient safety in Illinois, including the use of e-prescribing by all providers and a Division of Patient Safety within the state public health department.

This article reports on a Washington state law that prevents pharmacists from accepting prescriptions that are handwritten unless they are very clearly printed.

This Web site includes tools to help raise awareness about potential medication errors associated with using certain abbreviations. The tools are made available by Institute for Safe Medication Practices (ISMP) and U.S. Food and Drug Administration (FDA) as part of their national educational effort to eliminate the use of these abbreviations.

Prior research has demonstrated that intensive care unit patients are particularly vulnerable to medical error. This survey of critical care nurses examined the frequency, types, and causes of self-reported errors. Errors were frequent, with more than a quarter of nurses committing at least one error during the 28-day study period, and an even greater proportion reported "near errors" (where the nurse caught herself before the error was committed).