Background: Incident reporting is widely used in hospitals to improve patient safety, but current reporting systems do not function optimally. The utility of incident reports is limited because hospital staff may not know what to report, may fear retaliation, and may doubt whether administrators will review reports and respond effectively.
Methods: This is a clustered randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety.
We present technology enhancements that support the safe use of U-500 insulin.
View Article and Find Full Text PDFUsing chloral hydrate carries a risk of adverse events and compounding errors, and much of the available literature recommends using alternative sedatives for pediatric patients. But evidence regarding the efficacy of chloral hydrate and of alternative agents is conflicting.
View Article and Find Full Text PDFAccidental IV administration of heparinized irrigation solution occurs frequently. Two cases from ISMP Canada offer some safe practice recommendations.
View Article and Find Full Text PDFImplementing IT in medication-use systems reduces adverse drug events by decreasing human error. But over-reliance on technology can lead to automation bias and complacency.
View Article and Find Full Text PDFIndication-based prescribing has many potential benefits, including preventing errors by reducing medication choices and assisting with medication reconciliation.
View Article and Find Full Text PDFThe familiar but ambiguous on prescriptions are often of limited help to patients and pharmacists. Sometimes, the instruction to "use as directed" has resulted in serious errors.
View Article and Find Full Text PDFNeuromuscular blockers have been inadvertently administered to patients who were not receiving proper ventilatory assistance, causing death or permanent injuries.
View Article and Find Full Text PDFIncorrectly prescribed medications can have serious implications, especially in young children. Safe practice recommendations include listing patients' age, weight, and date of birth on prescriptions, verifying discharge orders, and involving pharmacists in reconciliation.
View Article and Find Full Text PDFLeftover or improperly discarded drugs are easy prey for diversion and are fueling the opioid abuse epidemic. ISMP offers safe practice recommendations to prevent drug misuse.
View Article and Find Full Text PDFThe final part of a 3-part series discusses medication safety risks related to labeling, patient education, and medication storage.
View Article and Find Full Text PDFPart 2 of a 3-part series discusses medication safety risks related to labeling, patient education, and medication storage.
View Article and Find Full Text PDFPart 1 of a 3-part series discusses 3 medication safety risks that can easily fall off the radar screen in hospitals and doctors' offices.
View Article and Find Full Text PDFManaging home infusion patients in the hospital and emergency department.
View Article and Find Full Text PDFAccidental overdoses involving fluorouracil infusions.
View Article and Find Full Text PDFErrors with flecainide suspension in children.
View Article and Find Full Text PDFContainer mix-ups and syringe swaps in the surgical environment.
View Article and Find Full Text PDFThe absence of a drug-disease interaction alert leads to a child's death.
View Article and Find Full Text PDFInpatients with Parkinson's disease require precise medication management.
View Article and Find Full Text PDFEpinephrine for anaphylaxis: Autoinjector or 1-mg vial or ampoule?
View Article and Find Full Text PDFMisidentification of alphanumeric symbols plays a role in errors.
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