Journal of patient safety
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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.
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Journal of patient safety · Jun 2009
Color coded medication safety system reduces community pediatric emergency nursing medication errors.
To compare the performance of current systems in place for preparation and administration of pediatric medications in community emergency departments to the color-coded medication safety (CCMS) system among nurses. ⋯ The CCMS system reduces pediatric medication delay and improves nursing accuracy. This is important in the community ED setting where many children receive emergency care and where providers may lack familiarity with pediatric medication dosing.
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Journal of patient safety · Jun 2009
Pediatric safety incidents from an intensive care reporting system.
Adverse events impose a great burden on patients and the health care system, but not enough is known about how to address incidents involving pediatric patients. This study examined the demographic factors, types of events, contributing system factors, and harm associated with incidents that occur in pediatric intensive care units. ⋯ Pediatric patients are commonly harmed in intensive care units. There are several potential ways to improve safety including protocols for high-risk procedures involving lines and tubes, improved monitoring, and staffing, training and communication initiatives. Providers may be able to identify patients at increased risk for harm and intervene to protect patient safety.
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Journal of patient safety · Mar 2009
Multicenter StudyIncidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study.
In recent years, medication error has received considerable attention because it causes substantial mortality, morbidity, and additional health care costs. Collecting information in this field depends on the willingness of health professionals to report their errors. Another important point is to identify patients at high risk for an adverse drug event (ADE) to oversee the quality of the entire drug distribution chain, including prescription, drug choice, dispensing, and preparation to the administration of drugs. ⋯ This study argues the need for pharmacovigilance to extend its scope to medication errors to improve the safety of drugs. Our results underlined that medication errors are likely to be more serious than ADRs. Our approach based on the collaboration between the pharmacovigilance center and clinicians can be a powerful tool for incorporating error reporting into the culture of medicine.