ISMP: Drawn Curtains, Muted Alarms, and Diverted Attention: Tragedy in the PACU

ISMP

Drawn Curtains, Muted Alarms, and Diverted Attention: Tragedy in the PACU

 

Last April, a 17-year-old girl died following an uncomplicated tonsillectomy performed in an outpatient ambulatory surgery center after receiving a dose of IV fentaNYL in the postanesthesia care unit (PACU). The case made headline news again recently when a civil lawsuit filed by the teen’s parents was resolved. While it is too late to reverse the tragic outcome of this case, we call upon all hospitals and outpatient surgery centers to learn from the event and take action to prevent a similar tragedy in their facilities.

Read More »

Editor’s Notebook: Personal Accountability

Editor’s Notebook

Personal Accountability

 

I’m struck by the number and variety of patient safety initiatives that individuals, organizations, and government entities have underway. We’re engaged in so many different activities in the name of safety and quality, it’s hard to tell if we’re headed collectively toward a coherent goal. Despite success stories and pockets of excellence, many still wonder if we’re better off than we were a decade ago. In patient safety, how can we be sure that we’re cultivating a forest and not just a vast collection of specimen trees?

Read More »

Fall Prevention: No, Falls Are Not Inevitable

Special Advertising Section

Fall Prevention: No, Falls Are Not Inevitable

Patients fall. It’s a fact of hospital life. Weakened by illness or surgery, confused by medication or aging, patients try to do more than they can and the result is often a fall. It might be a fall from bed, a fall while trying to walk unsupported, a fall when trying to get up from a chair. These things happen all too regularly. As caregivers, your job is to prevent those falls from happening.

Read More »

Enhancing Clinical Education and Training, Improving Care

Enhancing Clinical Education and Training, Improving Care

More than a decade ago the Institute of Medicine published its landmark study, To Err is Human (2000), documenting an unacceptably high rate of medical errors, many of them resulting from poor clinical decision-making. In fact, surgeons in the United States make medical errors more than 4,000 times a year, which can result in permanent injury or death. These types of preventable errors include wrong-site surgery, retained surgical items, wrong-patient surgery, and wrong-procedure surgery, causing nearly half of the affected patients to suffer temporary injury (Landro, 2012).

Read More »

A Team Approach to Fall Prevention

A Team Approach to Fall Prevention

Falls are a growing health concern, especially within the acute care arena. A fall is defined as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (Johnson et al., 2011). More than 30% of adults age 65 and older fall each year (Centers for Disease Control and Prevention, 2011), and up to 50% of adults age 85 and older fall each year (Bohl et al., 2010). With the aging population, the incidence of falls is only expected to increase.

Read More »

Mentoring Programs: Essential for Sustaining a Culture of Safety

Mentoring Programs: Essential for Sustaining a Culture of Safety

 

An effective mentoring program can strengthen a healthcare enterprise’s performance in many areas, including quality improvement, risk management, personnel recruitment and retention, staff education, and leadership. By enhancing staff knowledge and team integration, mentoring programs help support an enterprise-wide culture of safety, which, in turn, helps minimize adverse patient occurrences and related financial losses. This article examines the theory and practice of mentoring, focusing on how adult learning strategies and ongoing managerial support can improve mentor-mentee rapport and produce better outcomes for participating individuals and the organization.

Read More »

Patients and Families: Key Partners in Improving Patient Experience

Patients and Families:
Key Partners in Improving Patient Experience

Perhaps it is time for those of us in healthcare to realize that patients and families are no longer simply “receivers” of care offered by “providers.” In fact, the trend of engaged patients has taken on increasing significance in the larger healthcare dialogue.

Read More »

Intravenous Infusion Medication Safety: The Vision Becomes Reality

Intravenous Infusion Medication Safety:
The Vision Becomes Reality

In 2000 the Institute of Medicine (IOM) published To Err Is Human, the first in its groundbreaking series of reports that brought the issue of medication safety to national awareness. The Institute for Safe Medication Practices (ISMP) February 2002 Medication Safety Alert! suggested that “with computerized prescriber order entry (CPOE), barcode medication administration (BCMA), and now smart infusion pumps, we may finally have a solid defense against the most serious medication errors” (ISMP, 2002). While these three technologies have played a major role in improving medication safety, there are still opportunities for errors.

Read More »