The Risk of Workarounds

In April, Patient Safety and Quality Healthcare published an article summarizing a recent webinar presented through ourCenter for Safety and Clinical Excellence. The article is titled “Smart Pump Workarounds – What’s the Legal Risk?”, and it focuses on personal accountability on the part of caregivers in safely operating Smart IV pumps.

Caregiver accountability has been a hot topic in recent months. As it relates to IV medication safety, it’s a critical issue and worth paying attention to. It’s been shown that clinicians often implement process workarounds, including not utilizing the drug library, overriding soft dose and concentration alerts, reprogramming infusions as rate in ml/hr following hard limits, and occasionally removing IV tubing from pumps and delivering medication boluses by gravity to avoid a high dose alert.

Read More »

Study Shows Nurses Exposed to Risks During Insertion and Removal of Peripheral IV Catheter

Sandy, Utah—About one in two nurses experience blood exposure, other than from a needlestick, on their skin or in their eyes, nose or mouth at least once a month when inserting a peripheral intravenous (IV) catheter, according to a new study by the International Healthcare Worker Safety Center at the University of Virginia.[1] Exposure to blood carries the risk of infection from pathogens such as human immunodeficiency virus (HIV), hepatitis B (HBV), hepatitis C (HCV) and MRSA.

Read More »

Wander-Risk Patients: Best Practices for Hospitals and Assisted-Living Facilities

Wander-Risk Patients: Best Practices for Hospitals and Assisted-Living Facilities

Older adults and senior citizens with Alzheimer’s disease and other forms of dementia are at elevated risk of wandering away from their medical care facility, which poses unique challenges for the hospitals and specialized care facilities that house these patients. Wandering puts them in harm’s way; they could fall, get into an accident, become a crime victim, or suffer from exposure to the elements.

Read More »

AED Failures Connected to Deaths from Cardiac Arrest

Aug. 30, 2011—A study published online last week in Annals of Emergency Medicine reports that more than 1,000 cardiac arrest deaths over 15 years were connected to the failure of automated external defibrillators (AEDs); battery failure accounted for almost one-quarter of the failures.

Read More »

AAMC Announces “Best Practices for Better Care” Campaign

Washington, D.C., March 30, 2011—The AAMC (Association of American Medical Colleges) announced a new multi-year effort, Best Practices for Better Care, that harnesses the unique missions of academic medicine—medical education, patient care, and research—and applies them to the challenges of improving quality and safety in health care.

Read More »

ISMP: Oops, Sorry, Wrong Patient!

ISMP

Oops, Sorry, Wrong Patient!

Applying the JCAHO “two-identifier” rule beyond the patient’s room

When we think of “wrong patient” errors, the most common scenario that comes to mind is a nurse walking into a patient’s room and administering medications intended for one patient to another patient — often a roommate. However, “wrong patient” errors occur in a variety of ways.

Read More »