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Approach to Improving Safety
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Search results for "United States of America"

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Journal Article > Commentary

Medication safety in the neonatal intensive care unit: big measures for our smallest patients.

Rostas SE. J Perinat Neonatal Nurs. 2017;31:15-19.

Medication errors are common in the neonatal intensive care unit. This commentary outlines various strategies one teaching hospital has utilized to reduce risks of medication errors in this care setting, such as use of computerized provider order entry and smart pumps.

Journal Article > Commentary

Using computerized prescriber order entry to limit overrides from automated dispensing cabinets.

Drake E, Srinivas P, Trujillo T. Am J Health Syst Pharm. 2016;73:1033-1035.

Automated dispensing cabinets have been adopted in hospitals to enhance medication safety. These drug dispensing systems enable override functions so that nurses can access medications without pharmacist verification to ensure timeliness, but this workaround requires a reliable process to reduce the potential for errors. This commentary discusses how one hospital designed an oversight process using computerized provider order entry to increase the safety of this practice.

Journal Article > Study

Risk factors for i.v. compounding errors when using an automated workflow management system.

Deng Y, Lin AC, Hingl J, et al. Am J Health Syst Pharm. 2016;73:887-893.

Mistakes during preparation of intravenous (IV) medications can lead to dosing errors and adverse drug events. Analyzing data collected over 12 months in a hospital's automated IV compounding workflow management system, this study found that IV compounding errors occurred in less than 1% of cases and were usually intercepted through the automated system. These results suggest that existing processes do support safe medication use.

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 > Commentary

Maximizing smart pump technology to enhance patient safety.

Makic MBF. Clin Nurs Spec. 2015;29:195-197.

Smart pumps are considered a valuable method to improve medication safety. However, users may engage in workarounds that bypass the safety features of the equipment. This commentary relates risks and benefits associated with smart pumps and highlights opportunities to augment adoption and use of smart pump technology to prevent medication errors. A past AHRQ WebM&M perspective describes the value of smart pump technologies as a medication safety strategy.

Journal Article > Study

Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center.

Rochais E, Atkinson S, Guilbeault M, Bussières JF. J Pharm Pract. 2014;27:150-157.

Nurses felt that the introduction of automated dispensing cabinets improved medication safety and made their work easier.

Journal Article > Commentary

Increasing the use of 'smart' pump drug libraries by nurses: a continuous quality improvement project.

Harding AD. Am J Nurs. 2012;112:26-35. 

This commentary details how one hospital successfully increased use of smart pumps to improve medication safety.

Newspaper/Magazine Article

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

This news article reviews actual and potential medication errors submitted to the Institute for Safe Medication Practices in 2010 and provides recommendations to address them.

Newspaper/Magazine Article

Drug shortages: a pharmacy informatics perspective.

Edillo PN. Pharm Purch Prod. April 2011;8:26.

This article describes the impact of medication shortages on health systems and discusses how to manage them.

Newspaper/Magazine Article

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

This piece identifies situations in which patient verification errors occur and provides strategies to address them.

Newspaper/Magazine Article

Guidelines for timely medication administration: response to the CMS "30-minute rule."

ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.

This article reports results from a survey on the Centers for Medicare & Medicaid Services "30-minute rule" and provides a set of revised guidelines.

Newspaper/Magazine Article

ISMP updates its list of drug name pairs with Tall man letters.

ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.

This article reports results of a national survey on how "tall man" lettering has clarified high-consequence drug name confusion and includes a list of medication name pairs in such lettering.

Newspaper/Magazine Article

CMS 30-minute rule for drug administration needs revision.

ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.

This piece highlights nurses' responses to a national survey that explored problems associated with the Centers for Medicare and Medicaid Services (CMS) medication administration timing requirement.

Journal Article > Study

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals.

Wakefield DS, Ward MM, Loes JL, O'Brien J. J Am Med Inform Assoc. 2010;17:584-587.

Uptake of health information technology has been slow, especially in smaller hospitals and ambulatory practices. This article describes the successful implementation of an electronic medical record in a group of rural and critical access hospitals.

Legislation/Regulation > Organizational Policy/Guidelines

ASHP guidelines on the safe use of automated dispensing devices.

Am J Health Syst Pharm. 2010;67:483-490.

This document shares goals and objectives to enhance use of automated dispensing devices for pharmacists, other practitioners, and information system professionals.

Journal Article > Study

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

This study reports on a quality improvement effort to eliminate errors due to look-alike, sound-alike medications.

Newspaper/Magazine Article

Shakespeare was on target—don't be a borrower or lender.

ISMP Medication Safety Alert! Acute Care Edition. November 19, 2009;14:1-3.

This piece describes the dangers of "borrowing" dispensed medications as a workaround in the presence of pharmacy delays and shares strategies to eliminate the practice.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:730-733.

This monthly selection of error reports discusses incidents involving insulin preparation, automated medication cabinet stocking, and medication list filing.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.

Tools/Toolkit > Measurement Tool/Indicator

Medication Safety Self Assessment for Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; 2009.  

This tool aims to help hospitals evaluate and improve medication safety practices relating to the use of automated dispensing cabinets.

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