Design for Reliability: Barcoded Medication Administration

By Avis C. Hayden, PhD; Edward T. Lanoue, BSPharm, RPh; and Charles J. Still, MBA

There is now widespread agreement that hospital patients can be harmed by medication errors. Providing patients with medications in the acute care setting is a complex process that requires coordination in the flow of information when individuals order, transcribe, verify, dispense, and administer a medication. Early studies quantified the extent to which errors occur at each of these stages; one of the most troubling steps in the process is the administration phase, when 26 to 38% of the errors occur (Bates et al., 1995; Leape et al., 1995).

In Pursuit of a Patient-Centered VA Prescription Label

By Erin Y. N. Narus, PharmD, RPh; and Joe D. Youngblood, RPh

The patient-centered prescription label movement has roots in primary research studies by notable health literacy proponents (Davis et al., 2006; Davis et al., 2008; Shrank et al., 2007; Sharnk, Avorn et al., 2007). This foundational work paved the way for setting standards for prescription label formats, content, lexicon, and numeracy interpretation.

Barcode Technology for Positive Patient Identification Prior to Transfusion

Renewed initiative engages nurses and achieves 100% compliance. 

By Eileen L. Stone, BS, MT(ASCP), MS; Patricia Sherwood Keenan, RN, MSN, CPHQ, HACP

In today’s increasingly complex, highly demanding clinical environment, introducing a new technology is challenging under the best of circumstances. What if, right when roll-out is going well, an unrelated connectivity interruption leads nurses to conclude “this doesn’t work”? You need to get your initiative back on track—especially when it relates to improving the safety of a critically important patient-care process.

Applying the IHI Global Trigger Tool to Pediatric and Special Needs Populations

By Christine Milbrath, RN, EdD; Gail Pries, RN, MBA; Pam Howard, RN, BA; and Gayle Huseth, RN

Gillette Children’s Specialty Healthcare (Gillette) provides specialized healthcare services to individuals with disabilities, with a primary focus on children. Serving a wide geographic region, Gillette’s programs focus on the needs of patients with cerebral palsy, spina bifida, neuromuscular diseases, brain and spinal cord injuries, and complex neurological, craniofacial, and orthopedic conditions.

Forever Changed: Shared Learning in Patient Safety

By Yvonne Zawodny, RN, LHRM, CPHRM; and Geri Schimmel, RN, MS, LHRM

In an effort to promote patient safety, Baptist Health South Florida (Baptist Health) has instituted the Shared Learning process, the purpose of which is to educate and communicate with all stakeholders—our clinical staff, the Quality and Patient Safety Steering Council, and board members—in a proactive way.