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 · 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 · 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 · 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.