Journal of patient safety
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At our institution, we observed an increase in opioid-related adverse events after instituting a new pain treatment protocol. To prevent this, we programmed the Omnicell drug dispensing system to page the RRT whenever naloxone was withdrawn on the general wards. ⋯ Naloxone-triggered activation of the RRT resulted in reduced opioid-related inpatient cardiac arrests without adversely affecting pain satisfaction scores.
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Journal of patient safety · Mar 2017
Integrating Data From the UK National Reporting and Learning System With Work Domain Analysis to Understand Patient Safety Incidents in Community Pharmacy.
To explore the combined use of a critical incident database and work domain analysis to understand patient safety issues in a health-care setting. ⋯ Combining the insights from different analytical methods improves understanding of patient safety problems. Incident reporting data can be used to identify general patterns, whereas the work domain analysis can generate information about the contextual factors that surround a critical task.
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Journal of patient safety · Dec 2016
Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana.
This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana. ⋯ This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.
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Journal of patient safety · Sep 2016
Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department.
Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events. ⋯ Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.
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Journal of patient safety · Jun 2016
Comparative StudyContinuous Mandatory Onsite Consultant Intensivists in the ICU: Impacts on Patient Outcomes.
The aim of this study was to compare the impacts on patient outcomes of continuous versus on-demand access to certified consultant intensivists in the intensive care unit (ICU). ⋯ An improved survival rate was observed only among medical patients admitted to the ICU with mandatory continuous access to a consultant intensivist, despite the presence of greater disease severity in the population admitted to this unit.