The lingering safety menace: A 10-year review of enteral misconnection adverse events and narrative review.

In 2011, "Tubing Misconnections: Normalization of Deviance" reported >100 cases of enteral tubing misconnections leading to patient harm. Despite development of safer enteral device connectors, 96 new cases of enteral misconnections have been published since 2011. Publication and safety databases were searched for reports from 2011 to 2023.

Development of the invasive candidiasis discharge [I Can discharge] model: a mixed methods analysis.

Patients with invasive candidiasis (IC) have complex medical and infectious disease problems that often require continued care after discharge. This study aimed to assess echinocandin use at hospital discharge and develop a transition of care (TOC) model to facilitate discharge for patients with IC. This was a mixed method study design that used epidemiologic assessment to better understand echinocandin use at hospital discharge TOC.

Training Leaders in Health Informatics.

Despite the widespread adoption of electronic health records (EHRs) in the U.S. over the past decade, significant improvements, especially in patient safety, have yet to be realized.

Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings.

Background: In early 2016 the Partnership for Health IT Patient Safety released safe practice recommendations for the use of copy-paste for electronic health record (EHR) documentation. These recommendations do not directly address nurses' use of copy-forward to document patient assessments in flow sheet software in hospital settings. Similar to clinicians' use of copy-paste and copy-forward with progress notes, concerns exist about patient safety issues from the use of potential inaccurate or outdated information to achieve increased efficiency of documentation.

Tubing misconnections: normalization of deviance.

Background: Accidental connection of an enteral system to an intravenous (IV) system frequently results in the death of the patient. Misconnections are commonly attributed to the presence of universal connectors found in the majority of patient care tubing systems. Universal connectors allow for tubing misconnections between physiologically incompatible systems.

Neonatal intensive care unit and emergency department nurses' descriptions of working together: building team relationships to improve safety.

Teamwork is considered a critical factor in delivering high-quality, safe patient care although research on the evidence base of the effectiveness of teamwork and communication across disciplines is scarce. Health care providers have limited educational preparation for the communication and complex care coordination across disciplines required by today's complex patients. Complex work environments are affected by little understood human factors including the intricacies of human communication and behavior.

Cause-and-effect mapping of critical events.

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 in improving quality have been working in other high-risk industries since the 1920s making structured organizational changes through various frameworks for quality methods including continuous quality improvement and total quality management.

Enteral feeding misconnections: an update.

Enteral misconnections are defined as inadvertent connections between enteral feeding systems and nonenteral systems such as intravascular lines, peritoneal dialysis catheters, tracheostomy tube cuffs, medical gas tubing, and so on. Sentinel event data and causative factors are outlined along with potential solutions to prevent such medical errors. The solutions can be grouped into 3 areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes.

Reexamining fatigue: implications for nursing practice.

A growing body of scientific evidence demonstrates negative effects of fatigue on human performance. Nursing practice encompasses many tasks that require optimal performance. Fatigue can be the result of a multitude of contributing causes.

Threading needles in the dark: the effect of the physical work environment on nursing practice.

Frequently, the most critical calculations, considerations, and preparations for patient care and medication administration are made in noisy, dimly lit, and chaotic areas of the nursing unit. Healthcare has begun to recognize the impact of the physical work environment plays in the ability of humans to perform reliably and safely. This article reviews the draft guidelines recently released by the United States Pharmacopeia for public comment for the physical environment to promote safe medication administration.

Tubing misconnections--a systems failure with human factors: lessons for nursing practice.

In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in health care's view of vigilance.

Error-avoidance recommendations for tubing misconnections when using Luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.

Recommendations are provided to assist health care professionals, manufacturers, and consumers in the appropriate handling of tubing with Luer-tip connectors.

Enteral feeding misconnections: a consortium position statement.

A consortium of organization identified solutions to the problem of enteral feeding misconnections in three areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes.

Sedation and patient safety.

The safety of patients receiving sedation and sedating analgesia therapies is a system property. There are multiple team members and processes needed to ensure safety that reside outside the purview of nursing. This article outlines safety considerations in sedation using the Eindhoven classification system as framework for aggregating contributing factors in error events into a useful format.