Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Mar 2012
A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.
As with the use of any therapy involving opioids, patient-controlled analgesia (PCA)-related errors can lead to overdose and even death. "Smart" (computerized) pumps have medication safety enhancements, particularly those related to operator errors during administration, to improve overall safety and efficacy. After the occurrence of PCA-related errors that occurred at a tertiary care academic medical center, an analysis of PCA errors was conducted. The introduction of smart pumps was identified as a possible solution, and the medical center adopted the technology in 2006. A study was conducted to investigate the impact of implementation. ⋯ Smart PCA pumps had an important positive impact on PCA-related patient safety at the medical center. Other facilities should adopt PCA devices with additional safety features such as bar-code verification of the drug and concentration, as well as dosage limits, to prevent pump-programming errors.
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Jt Comm J Qual Patient Saf · Mar 2012
Implementing a perioperative handoff tool to improve postprocedural patient transfers.
Handoffs in the perioperative setting--the period during which the patient leaves the operating room (OR) and arrives at the postanesthesia care unit (PACU) or intensive care unit (ICU)--have received little attention. A perioperative handoff tool consisting of an OR-to-ICU/PACU protocol and checklists incorporates a defined process, a specified team structure, a procedure for technology transfer, and clearly defined information elements to share. The tool could be applied to any periprocedural setting in which a patient is physically transferred from the procedural location (with the associated procedural team) to a postprocedural care unit with a different care team.