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Search results for "United States of America"

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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

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.

Journal Article > Commentary

Medication errors in outpatient pediatrics.

Berrier K. MCN Am J Matern Child Nurs. 2016;41:280-286.

Medication errors occur in various care environments, and they are common in the outpatient setting. This commentary describes factors that contribute to incorrect medication administration by parents, such as misunderstanding of instructions due to insufficient health literacy. The author proposes several tactics to promote safe medication practices by parents which include picture-based instructions and standardized dosing instruments.

Newspaper/Magazine Article

What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2016;21:1-3.

If cost-saving decisions are made without adequate consideration, they can increase risks. This newsletter article raises awareness that alternative epinephrine administration methods used to reduce device costs can introduce heightened potential for dosing errors and lead to serious patient harm.

Journal Article > Study

An acetaminophen icon helps reduce medication decision errors in an experimental setting.

Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.

Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.

Newspaper/Magazine Article

Correct use of inhalers: help patients breathe easier.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.

Patients and clinicians can make medication administration mistakes when new drug delivery mechanisms are introduced. This newsletter article reviews common errors associated with the use of inhalers and offers recommendations for patients, nurses, respiratory therapists, pharmacists, and health care organizations to educate patients on the use of these medications.

Journal Article > Review

Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors.

Wolf ZR. J Infus Nurs. 2016;39:235-248.

Errors in administration of intravenous medications have potential to cause severe patient harm. This study analyzed medication administration errors voluntarily reported to the Institute for Safe Medication Practices. The investigator found that the most frequent error was excessive dosing and most errors were multifactorial, consistent with prior studies.

Journal Article > Study

Standardization of compounded oral liquids for pediatric patients in Michigan.

Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.

When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.

Journal Article > Study

Nursing strategies to increase medication safety in inpatient settings.

Bravo K, Cochran G, Barrett R. J Nurs Care Qual. 2016;31:335-341.

Medication administration errors are common and are often associated with interruptions. This study reviews data from a recent study on medication safety in critical access hospitals and recommends organizational strategies to improve the safety of medication administration.

Journal Article > Study

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

Schnock KO, Dykes PC, Albert J, et al. BMJ Qual Saf. 2017;26:131-140.

Medication errors associated with intravenous smart pumps are a safety concern. Because errors are not always reported, the magnitude of this problem has been unknown. In this study, direct observation of nurses using smart pumps revealed that 60% of medication infusions involved one or more errors, but actual harm to patients was rare. The most common errors involved incorrect infusion rates and workarounds like bypassing the smart pump. These results accentuate a need for improvements in smart pump design to enhance safety and usability. A previous WebM&M commentary describes consequences of an incorrect medication infusion.

Journal Article > Study

US poison control center calls for infants 6 months of age and younger.

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Kang AM, Brooks DE. Pediatrics. 2016;137:1-7.

Pediatricians commonly advise parents to keep medications and chemicals inaccessible to their young children to avoid accidental ingestions. With the assumption that infants will not be mobile enough to access potentially harmful substances, providers typically begin these conversations with parents when children are age 6 months. This retrospective study reviewed 10 years of calls to poison control centers for infants younger than 6 months. Nearly 97% of the 271,513 exposures were unintentional. Half were coded as "general unintentional," which includes exploratory exposures and other scenarios leading to access, such as a sibling providing a substance to the child. Therapeutic errors, such as dosing mistakes, accounted for another 37% of exposures. Some parents self-triaged to a health care facility prior to speaking to poison control, which may be due to unawareness among parents of young infants about the availability of poison control consultation. The authors suggest this study may help guide future poison education and prevention efforts.

Journal Article > Commentary

Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework.

Kelly K, Harrington L, Matos P, Turner B, Johnson C. J Nurs Adm. 2016;46:30-37.

Successful barcode medication administration implementation can reduce unintended consequences and workarounds related to poor system design. This commentary discusses an evaluation process that engages hospital leaders and frontline nurses in reviewing evidence, assessing practice, improving performance, and modifying processes to enhance the safety of barcoded medication use.

Book/Report

2016–2017 Targeted Medication Safety Best Practices for Hospitals.

Horsham, PA: Institute for Safe Medication Practices; 2015.

This updated report outlines 11 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to storage and use of neuromuscular blocking agents, smart pumps, and standardized protocols for rescue agents.

Journal Article > Commentary

Best practices for chemotherapy administration in pediatric oncology: quality and safety process improvements (2015).

Looper K, Winchester K, Robinson D, et al. J Pediatr Oncol Nurs. 2016;33:165-172.

Chemotherapy is a high-risk treatment that requires specific safety protocols. This commentary describes an effort that successfully determined and implemented best practices for chemotherapy administration in children. The intervention included an interdisciplinary program that reviewed current processes and evidence, utilized quality improvement tools, and established standardized techniques, exact times, and consistent documentation to augment safety associated with use of this medication.

Journal Article > Study

Risk propensity and safe medication administration.

Gonzales K. J Patient Saf. 2015;11:166-173.

This survey study found that nursing students' more personal risk-taking behavior was associated with lower knowledge and performance of safe medication administration, suggesting that a personal trait could affect safety practices among nursing trainees.

Journal Article > Commentary

Reducing continuous intravenous medication errors in an intensive care unit.

O'Byrne N, Kozub EI, Fields W. J Nurs Care Qual. 2016;31:13-16.

This commentary describes the results of a two-phase initiative intended to reduce errors related to intravenous medication administration and line reconciliation in a surgical intensive care unit. The program used various educational methods and a systematic approach based on the five rights of medication safety.

Journal Article > Commentary

Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses.

Hayes C, Power T, Davidson PM, Daly J, Jackson D. Nurse Educ Today. 2015;3:981-986.

Interruptions pose a significant safety hazard for health care providers performing complex tasks and increase the risk of errors. This commentary describes a simulated training initiative to help prepare nursing students for experiencing and responding to interruptions during medication administration.

Book/Report

Guidelines for Adult IV Push Medications.

Horsham, PA: The Institute for Safe Medication Practices; July 2015.

To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.

Newspaper/Magazine Article

Innovation in practice: a multidisciplinary medication safety initiative.

Eid KA. Nursing. 2015;45:14-16.

Robust processes that enable review and analysis of medical errors are critical to support organizational learning. This commentary highlights one institution's experience convening a multidisciplinary committee focused on improving medication administration through analysis of medication-related incidents and implementing interventions based on the group's findings.

Journal Article > Commentary

Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model.

Guenter P, Boullata JI, Ayers P, et al; Parenteral Nutrition Safety Task Force, American Society for Parenteral and Enteral Nutrition. Nutr Clin Pract. 2015;30:570-576.

Parenteral nutrition has the potential to result in patient harm if administered or prepared incorrectly. This commentary builds on a set of overarching recommendations to define competencies that enable the safe prescribing and delivery of parenteral nutrition. The model is designed to help organizations apply the suggestions in their particular care environments.

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