Search results for "United States of America"

Diabetes medications are known to be high risk for adverse drug events. This case study reviews several patient safety measures for electronic prescribing for diabetes in outpatient care. Researchers describe an adverse drug event involving electronic prescribing of insulin and detail how the incident could have been prevented. Electronic prescribing is not currently standardized and may require using a trade name for medications, which may lead to prescribing errors. Adoption of the medication naming conventions put forth by the National Library of Medicine's RxNorm would prevent this vulnerability. Similarly, standardizing electronic prescribing orders for high-risk medications like insulin may reduce the risk of erroneously choosing a long-acting instead of short-acting insulin formulation, which can have life-threatening consequences. The authors advocate for using Universal Medication Schedule instructions and providing language-concordant labels to patients to support safe medication self-administration. They suggest that real-time, bidirectional communication between prescribers and pharmacists may improve safe prescribing. The authors conclude that recommended safety practices are not uniformly implemented in clinical practice and advocate for implementation research to ensure medication safety for outpatients with diabetes.

Communication breakdowns in the operating room are associated with preventable adverse events. This study examined the potential of a novel workflow management system—a computerized system which used voice recognition and built-in algorithms to ensure important procedural steps were undertaken appropriately—to improve patient safety. The system was able to detect when intraoperative tasks were being performed and successfully identified omitted steps as well.

Checklists can reduce risks of cognitive gaps that contribute to errors in health care. This commentary uses case studies to illustrate the potential value of an open-access online diagnostic checklist in neurological care to help physicians determine diagnoses.

Implementation of smart intravenous pumps was associated with fewer adverse events and considerable cost savings at an academic medical center.

This newspaper article reports how one hospital system introduced advanced training programs to ensure safe use of surgical robots.

This newspaper article discusses complications associated with surgical robots, and explains that such errors may have been exacerbated by inadequate clinician training and production pressures.

Adoption of smart infusion pump technology was intended to improve medication safety, but past reports describe the ability of nurses to create work-arounds. This study examined preventable intravenous adverse drug events (IV-ADEs) and discovered that only 4% could be intercepted by a smart pump. Investigators reviewed medical records, both before and after adoption of smart pumps, to draw these conclusions. They also provide a qualitative analysis of errors causing preventable IV-ADEs and propose solutions that would improve smart pump technology.

This article describes how robust drug libraries developed for programmable smart pumps can help reduce medication errors associated with traditional infusion methods.

The author discusses approaches to improving safety in the operating room, such as the use of robotics and simulation.

The authors conducted focus groups to assess nurses' experiences with using smart pumps and the ways in which they overcame challenges associated with this technology.

The authors suggest a model process utilizing failure mode and effects analysis to effectively implement emerging technologies that help minimize medication error.

The authors describe the implementation of intravenous medication administration software interfaced with "smart" infusion pumps.

New technology continues to offer great advances and challenges. This article takes a detailed look at technology's impact on human performance by studying the implementation of a new physiological monitoring system for use in cardiac anesthesia. Discussion includes characteristics of the upgraded system, a process-tracing technique to examine the complex physician-computer interaction, and the problems that developed while in use. The authors introduce a number of new cognitive burdens that resulted and discuss how providers attempted to overcome these burdens within the framework of the new system. Though it represents one example, the rich discussion in this article applies to most new technology and the human factors that require it to function as technically designed.