Abstract
We present a case of intravenous (IV) paracetamol overdose in a nutritionally malnourished child during hospital admission. A ten-fold IV paracetamol dosing error ocurred, with delayed recognition and treatment resulting in transient hepatotoxicity, with a peak alanine transaminase (ALT) of 1378 IU/...
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PMID: 22115056
PDF is available here.
Abstract
We report the results of reviews by pharmacists of clerical errors in drugs used in the operating room by anesthesiologists from August 2005 to March 2007 at Fukuoka University Hospital. During the period, 9907 surgical patients were managed by anesthesiologists. There were 4868 clerical errors by a...
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PMID: 22256588
PDF is available here.
Abstract
Incidents linked to the prescription of medications also referred to as "look-alike, sound-alike" are frequent both in the ambulatory and in hospital sectors. These incidents are associated with relevant morbidity and mortality. Next to other specialties of medicine, infectiology is...
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PMID: 22097445
PDF is available here.
Abstract
Implementing an appropriate drug dispensing system in hospitals is essential to ensure the safe and rational use of drugs. This study aimed to assess the unit-dose drug dispensing system (DDS) and the ward-stock DDS utilized in Gaza hospitals to ascertain which system is more benefic...
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PMID: 22256404
PDF is available here.
Lynn R LR Webster,
Susan S Cochella,
Nabarun N Dasgupta,
Keri L KL Fakata,
Perry G PG Fine,
Scott M SM Fishman,
Todd T Grey,
Erin M EM Johnson,
Lewis K LK Lee,
Steven D SD Passik,
John J Peppin,
Christina A CA Porucznik,
Albert A Ray,
Sidney H SH Schnoll,
Richard L RL Stieg and
Wayne W Wakeland
Abstract
A panel of experts in pain medicine and public policy convened to examine root causes and risk factors for opioid-related poisoning deaths and to propose recommendations to reduce death rates.
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PMID: 21668754
PDF is available here.
Abstract
Hoping to reduce medication errors and contain health care costs, policy makers are promoting electronic prescribing through Medicare and Medicaid financial incentives. Many e-prescribing systems provide electronic access to important information--for example, medications prescribed by physicians in...
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PMID: 21545050
PDF is available here.
Abstract
To demonstrate for first-year pharmacy students the relevance of pharmaceutics course content to pharmacy practice by implementing a joint, integrated assignment in both courses and assessing its impact.
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PMID: 21655398
PDF is available here.
Abstract
Aminoglycosides are used to treat aerobic gram-negative infections and can be administered with other antibiotics to treat resistant gram-positive infections. Aminoglycosides are most often administered topically or parenterally. During the surgical period, surgeons may use aminoglycosides to irrigat...
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PMID: 21459184
PDF is available here.
Abstract
We defined initially inappropriate antibiotic therapy as occurring when the patient either was not administered an antibiotic within 24 hrs of sepsis onset or was treated with an antibiotic to which the culprit pathogen was resistant in vitro. The cohort included 760 subjects (mean age 59.3 ± 16.3...
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PMID: 20890186
PDF is available here.
Abstract
Elderly patients are at an increased risk of developing adverse drug events due to polypharmacy, co-morbidity and changes in physiology. Often, pharmacotherapy in frail elderly patients is initiated based on randomized trials from which this population has been excluded. In such cases, the question w...
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PMID: 21914235
PDF is available here.
Abstract
Despite increasing recognition of the significance of learning from errors, little is known about how learning climate contributes to error reduction.
The purpose of this study was to investigate whether learning climate moderates the relationship between error-producing conditions and medication er...
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PMID: 21127452
PDF is available here.
Abstract
Administering medication is an important function of registered nurses. It is therefore necessary that nursing students develop knowledge and skill in this field. Given the propensity for, and negative consequences of, medication errors, it is essential that nursing students are prop...
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PMID: 22256554
PDF is available here.
Claire Chapuis,
Matthieu Roustit,
Gaëlle Bal,
Carole Schwebel,
Pascal Pansu,
Sandra David-Tchouda,
Luc Foroni,
Jean Calop,
Jean-François Timsit,
Benoît Allenet,
Jean-Luc Bosson and
Pierrick Bedouch
Abstract
We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction.
Preintervention and p...
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PMID: 20838333
PDF is available here.
Abstract
We conducted a review of the literature to determine the impact of health information technologies (HITs) on nurses and nursing care.
Nurses' effective use of HIT has the potential to produce a positive impact on nursing-sensitive patient outcomes, patient safety, and quality of care.
A review of th...
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PMID: 21084885
PDF is available here.
Abstract
Combination antiretroviral therapy (cART) has improved survival rates in HIV-infected patients; however, patients now experience comorbidities that require pharmacological intervention, thereby increasing the risk of drug-drug interactions (DDIs). HIV protease inhibitors (PIs), non-nucleoside revers...
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PMID: 20668439
PDF is available here.
Abstract
Our study suggests that the use of prefilled dry powder inhalers as well as inhalation instruction increases correct inhalation technique. Simultaneous use of different types of inhalation devices has to be discouraged....
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PMID: 20804428
PDF is available here.
Abstract
To improve patient safety, healthcare facilities are focussing on reducing patient harm. Automated harm-detection methods using information technology show promise for efficiently measuring harm. However, there have been few systematic reviews of their effectiveness.
To perform a systematic literatu...
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PMID: 20671081
PDF is available here.
Abstract
Medication errors (MEs) and adverse drug events (ADEs) are both common and under-reported in the intensive care setting. The definitions of these terms vary substantially in the literature. Many methods have been used to estimate their incidence.
A systematic review was done to assess methods used f...
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PMID: 20671079
PDF is available here.
Abstract
The Pennsylvania Patient Safety Authority Reporting System is a confidential, statewide Internet reporting system to which all Pennsylvania hospitals, outpatient-surgery facilities, and birthing centers, as well as some abortion facilities, must file information on medical errors. Safety Monitor is...
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PMID: 20736716
PDF is available here.
Abstract
Pharmacists have an important role in detecting, preventing, and solving prescription problems, which if left unresolved, may pose a risk of harming the patient.
The aim was to examine prescription problems detected at pharmacies in Sweden, where pharmacists consider it necessary to contact the pres...
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PMID: 20813331
PDF is available here.
Abstract
The safe prescribing, use, administration, and monitoring of medications are an important component of patient safety efforts and are of particular importance to the obstetrician/gynecologist. Safe use of medications requires a team-based approach focused on medication safety with effective 2-way co...
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PMID: 20661034
PDF is available here.
Abstract
We risk repeating old mistakes and creating new opportunities for error and inefficiency as illustrated by problems associated with computerized provider order entry systems.
This study was designed to elucidate principles underlying a successful ICU paper-based CIS. The research was guided by two e...
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PMID: 20346695
PDF is available here.
Abstract
Epoprostenol and treprostinil are intravenous prostacyclin medications used to treat pulmonary arterial hypertension (PAH). This survey explored hospital policies regarding prostacyclin infusions, and investigated the type and frequency of errors that occurred in the inpatient setting.
Information o...
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PMID: 20430649
PDF is available here.
Abstract
We share our experience of using computer software (Microsoft Office Excel) to improve the planning of patient care. This technology is now widely available and we suggest that it is feasible and, indeed, particularly valuable in a resource-poor setting. We focus on the steps taken to minimize the c...
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PMID: 20223798
PDF is available here.
Abstract
Medication errors are common throughout healthcare and result in significant human and financial cost. Prospective studies suggest that the error rate in anaesthesia is around one error in every 133 anaesthetics. There are several categories of medication error ranging from slips and lapses to fixat...
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PMID: 20507858
PDF is available here.
Abstract
Adverse drug events are common in the intensive care unit setting. Despite the existence of many long-standing safety principles (such as the "five rights") and new mechanisms to promote medication safety, there is still a gap between practice and the goal of patient safety. This is the result of th...
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PMID: 20502167
PDF is available here.
University of Colorado Denver Health Sciences Center, Denver, CO 80220, USA. David.spiegel@ucdenver.edu
Abstract
The rHuEPO dosing errors were large and on occasion greater than 100% at the 1,200 U dose. The variability for each RN, while large, was less than the inter-RN variability (within-RN % error 9.6% vs. 29.8% between-RN % error at the 1,200 unit dose). Errors occurred in both directions, both under- an...
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PMID: 20497757
PDF is available here.
Abstract
Health care is being compelled to adopt patient-centered care. Consumers, professionals, and health care and community organizations are partnering to bring the voice of patients to health care reform. Nurses may recognize some professional organizations involved, such as the Institute of Medicine a...
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PMID: 20541071
PDF is available here.
Abstract
Medication errors represent a failure in the medication use process and can increase morbidity and mortality. The National Coordinating Council for Medication Error Reporting and Prevention maintains a taxonomy that assists in standardized reporting, evaluating, and trending of medication error data...
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PMID: 20541067
PDF is available here.
Abstract
Errors totalled 301, the most common was overwriting of a prescription, the least common was incorrect dates. No resulting adverse events were recorded. CONCLUSION: The prevalence of errors needs to be reduced to avoid serious adverse incidents. Computerised physician order entry systems are discuss...
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PMID: 20583641
PDF is available here.
Abstract
In most inpatient settings, the complexity of care required by individual patients coupled with the wide range of services provided within a single institution mean patients are routinely cared for in highly specialized units. Service lines, such as surgical services; intensive care; emergency servi...
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PMID: 20541070
PDF is available here.
Abstract
Health care errors are routinely reported in the scientific and public press and have become a major concern for most Americans. In learning to identify and analyze errors health care can develop some of the skills of a learning organization, including the concept of systems thinking. Modern experts...
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PMID: 20541073
PDF is available here.
Abstract
This article identifies the risks involved in the preparation of parenteral medicines in clinical areas and describes ways in which these risks can be minimised. RELEVANCE TO CLINICAL PRACTICE: Use of risk assessment allows targeted transfer of high-risk parenteral medicines to pharmacy preparation,...
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PMID: 20579198
PDF is available here.
Abstract
We describe a patient who received an inadvertent bolus of noradrenaline and developed significant haemodynamic instability associated with electrocardiographic and cardiac biomarkers indicative of diffuse myocardial injury and echocardiography findings of an "inverted" TTC. The patient made a full...
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PMID: 20513218
PDF is available here.
Abstract
The incidence of ADEs was low when compared with non-intercepted PADEs. This was indicative of medication safety system failures that placed patients at risk for potential harm. Non-voluntary detection methods were much more effective at detecting events than traditional self-report methods....
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PMID: 20348558
PDF is available here.
Abstract
1 in 20 Spanish citizens is currently undergoing a potential drug interaction, including a high rate of clinically relevant ones that should be avoided. These results confirm the existence of a serious safety issue that should be approached and where all parties involved (physicians, health services...
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PMID: 20504263
PDF is available here.