Annals of emergency medicine
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Randomized Controlled Trial
A Randomized Controlled Trial on the Effect of a Double Check on the Detection of Medication Errors.
The use of a double check by 2 nurses has been advocated as a key error-prevention strategy. This study aims to determine how often a double check is used for high-alert medications and whether it increases error detection. ⋯ Our study demonstrates that nurses use double checks before administering high-alert medications. Use of a double check increases certain error detection rates in some circumstances, but not others. Both techniques missed many errors. In some cases, the second nurse actually dissuaded the first nurse from acting on the error.
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Case Reports
External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose Cardioversion.
The simultaneous use of 2 external defibrillators to administer either dual or sequential cardioversion or defibrillation for refractory cardiac arrhythmias is increasing in both the out-of-hospital and inhospital settings. Using 2 defibrillators to administer higher energy levels than can be achieved with a single defibrillator is considered off-label and is currently not part of published advanced cardiac life support guidelines. We report the first case in which the use of dual-dose cardioversion was associated with external defibrillator damage. Because defibrillator damage, especially if undetected, jeopardizes patient safety and off-label medical product use may void the manufacturer's warranty, this case should urge users to proceed with caution when contemplating this technique.