Qual Saf Health Care
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Qual Saf Health Care · Apr 2005
Insights from the sharp end of intravenous medication errors: implications for infusion pump technology.
Intravenous (IV) medication errors are a common type of error identified in hospitals and can lead to considerable harm. Over the past 20 years there have been several hundred FDA reported incidents involving IV pumps, many of which have led to patient deaths. ⋯ Medication errors associated with IV pumps occur frequently, have the potential to cause harm, and are epidemiologically diverse. Smart pumps are a necessary component of a comprehensive safe medication system. However, currently available smart pumps will fail to generate meaningful improvements in patient safety until they can be interfaced with other systems such as the electronic medical record, computerized prescriber order entry, bar coded medication administration systems, and pharmacy information systems. Future research should focus on the effectiveness of new technology in preventing latent and active errors, and on new types of error that any technology can introduce.
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Qual Saf Health Care · Feb 2005
Safety in the operating theatre - Part 2: human error and organisational failure.
Over the past decade, anaesthetists and human factors specialists have worked together to find ways of minimising the human contribution to anaesthetic mishaps. As in the functionally similar fields of aviation, process control and military operations, it is found that errors are not confined to those at the "sharp end". In common with other complex and well defended technologies, anaesthetic accidents usually result from the often unforeseeable combination of human and organisational failures in the presence of some weakness or gap in the system's many barriers and safeguards. ⋯ Errors at the sharp end are symptomatic of both human fallibility and underlying organisational failings. Fallibility is here to stay. Organisational and local problems, in contrast, are both diagnosable and manageable.
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Qual Saf Health Care · Dec 2004
Editorial CommentChallenges for an international guidelines collaboration.
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Qual Saf Health Care · Dec 2004
Clinical Trial Controlled Clinical TrialSimulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?
To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum. ⋯ High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training. This approach, using a number of patients, is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training. It is, however, unclear how much simulator based training must augment didactic teamwork training for clinically meaningful differences to become apparent.