Journal of patient safety
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Journal of patient safety · Sep 2009
The role of advice in medication administration errors in the pediatric ambulatory setting.
In the pediatric setting, adverse events occurring at the administration stage are the most common type of preventable adverse drug events. Few data are available on the effect of advice from medical professionals on medication safety. ⋯ Inadequate advice was provided. The current approach for delivering advice does not prevent against medication administration errors. Those at highest risk of such errors are the youngest children and those on multiple medications.
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Journal of patient safety · Sep 2009
Comparative StudyComparison of differing sedation practice for upper endoscopic ultrasound using expert observational analysis of the procedural sedation.
To compare the quality between 2 commonly used sedation practices for upper endoscopic ultrasound (EUS) by using expert observational analysis of the sedation practice. ⋯ Expert videotape analysis of the patient state during procedural sedation allows direct comparison of sedation methodologies using small numbers of patients. In our institution, endoscopist-directed sedation using a midazolam/narcotic combination for EUS proved inferior to sedation using propofol given by an anesthesiologist. Specifically, a midazolam/narcotic combination provided less effective intraprocedural conditions, was less efficient both before and after the procedure, and was less satisfactory to patients as compared with propofol. Results of this type of analysis can be used to drive appropriate system redesign and improve patient care.
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Journal of patient safety · Sep 2009
Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety.
Clear and complete communication between health care providers is a prerequisite for safe patient management and is a major priority of the Joint Commission's 2008 National Patient Safety Goals. The goal of this study was to describe nurses' perceptions of nurse-physician communication in the long-term care (LTC) setting. ⋯ A combination of nurse and physician behaviors contributes to ineffective communication in the LTC setting. These findings have important implications for patient safety and support the development of structured communication interventions to improve quality of nurse-physician communication.
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Journal of patient safety · Sep 2009
Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.
Since the publication of To Err is Human, health care professionals have looked to high-reliability industries such as commercial aviation for guidance on improving system safety. One of the most widely adopted aviation-derived approaches is simulation-based team training, also known as crew resource management (CRM) training. In the health care domain, CRM training often takes place in custom-built simulation laboratories that are designed to replicate operating rooms or labor and delivery rooms. ⋯ During the simulation, a number of latent environmental threats to safety were identified. The following article presents not only the latent threats but also the steps that the hospital has taken to remedy them. Results from clinical simulations in operational health care settings can help identify and resolve latent environmental threats to patient safety.