Pictograms for Safer Medication Management by Health Care Workers.

Background: Inherent risks are associated with the preparation and administration of medications. As such, a key aspect of medication safety is to ensure safe medication management practices.

Objective: To identify key medication safety issues and high-alert drug classes that might benefit from implementation of pictograms, for use by health care providers, to enhance medication administration safety.

Hospital-acquired acute hyponatremia and reports of pediatric deaths.

Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors.

Prevalence and clinical significance of medication discrepancies at pediatric hospital admission.

Objective: To quantify admission medication discrepancies in a tertiary-care, general pediatric population, to describe their clinical importance and associated factors, and to assess a screening approach to pharmacist involvement.

Methods: A total of 272 patients were studied prospectively at hospital admission. The study pharmacist performed a medication history and compared it to physicians' admission medication orders.

Handoffs in care--can we make them safer?

In today's complex and rapidly changing health care environments, patient harm may result if important patient information is not communicated from one health care provider to another during handoffs in care. Issues involving communication, continuity of care, and care planning are cited as a root cause in more than 80% of reported sentinel events. In light of the inherent risks associated with handoffs in care, the use of strategies that reduce the impact of human factors on effective communication and standardize the communication process is essential to ensure appropriate communication patient information and that a plan of care is continued through the process.

Patient safety in a pediatric centre: partnering with families.

Patient Centred Care (PCC) is a recognized pillar of quality healthcare. According to the Institute of Medicine (Kohn et al. 2000), PCC respects and is responsive to individual patient preferences, needs and values, and ensures they guide all clinical decisions.