Search results for "United States of America"

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.

Checklists and debriefing improve patient safety across multiple care settings. In this quality improvement initiative, participating hospitals reported high levels of adherence and satisfaction to a protocol for neonatal resuscitation that included a checklist, briefings, and debriefings. The authors advocate for these safety processes to be included in neonatal resuscitation guidelines.

The recent death of comedienne Joan Rivers, which followed a cardiac arrest during a routine throat procedure, has brought national attention to the potential safety hazards of office-based procedural anesthesia. This retrospective study examined adverse events associated with moderate procedural sedation performed outside of the operating room at a tertiary medical center. Adverse events were relatively rare, with only 52 safety incidents identified out of more than 140,000 cases over an 8-year period. The most common harm was oversedation leading to apnea and requiring the use of reversal agents or prolonged bag-mask ventilation. Women were found to be at particularly increased risk for adverse events including oversedation and hypotension. These findings suggest that a combination of patient and procedural characteristics may help risk stratify patients, allowing for appropriate responses such as increased monitoring and staffing for patients likely to experience sedation-related complications. A previous AHRQ WebM&M perspective described office-based anesthesia as the "Wild West" of patient safety.

Redesigning tubing connectors according to new ISO standards has the potential to reduce tubing misconnections. This commentary provides information about changes to enteral connectors to prepare clinicians to use the new devices in their organizations.

This educational study found that anesthesiology residents were more likely to initiate an airway technique for which they had received simulation training, even if another technique (for which they received didactic training) would have been more appropriate. This finding demonstrates how training may inadvertently introduce cognitive bias.

This commentary examines how residual medications in intravenous lines can harm patients and emphasizes the need for these incidents to be reported.

Reviewing the three major contributing factors to medical errors associated with hospital beds, this commentary recommends a risk assessment program to ensure hospital beds meet safety standards.

An advocate for clinical education (a nurse who rounded with medicine and surgery teams) provided team-specific feedback on patient safety measures to residents and attending physicians based on direct observation of clinical care. The feedback was well received by physicians and was associated with some improvement in hand hygiene practices.

Implementing a standardized checklist resulted in a significant reduction in the proportion of trauma patients who could not be successfully liberated from mechanical ventilation.

This publication presents findings from an investigation, prompted by reports of alarm fatigue, which identified gaps in training and competencies of nurses in 29 Veterans Health Administration facilities.

Missed nursing care (failure to perform required patient care elements) is surprisingly common. This qualitative study found that patients were able to reliably identify episodes of missed nursing care and their perceptions correlated with nurses' opinions.

This review explores simulation as a method to identify safety issues related to team, equipment, and system performance.

The obesity epidemic is considered an urgent public health issue in Europe and the United States. Although morbidly obese patients are prone to a variety of medical issues, no study to date has evaluated patient safety risks in this population. This retrospective analysis of errors voluntarily reported to the United Kingdom's National Patient Safety Agency documents more than 380 errors and near misses in which obesity was considered a contributing factor. The majority of errors were partly attributable to inadequate equipment for caring for such patients, particularly in the surgical and critical care environments. Based on these data, the authors advocate for multidisciplinary approaches to systematizing care for morbidly obese patients. The challenges of caring for obese patients are discussed in an AHRQ WebM&M commentary, which examined a case of an ultimately fatal delayed diagnosis in a morbidly obese woman.

Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.

Experts convened to discuss best practices for safe intravenous medication administration. This article reports on the results of that conference along with ways to implement the suggested practices.

The author discusses the use of digital technology in health care and describes how one facility is considering radio frequency identification to improve safety.

This article reports on recommendations developed by United States Pharmacopeia (USP) to improve the safety of using medical gas, including revisions to USP monographs.

This advisory from the Pennsylvania Patient Safety Reporting System discusses 125 reports of tourniquets being inappropriately left on patients and provides strategies to reduce these occurrences.

This article reports on inappropriate laser use by non-physicians for dermatological procedures. A study presented at the American Society for Laser Medicine and Surgery meeting found prevalent misuse of equipment and improper application.