Joint Commission journal on quality and patient safety / Joint Commission Resources
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Jt Comm J Qual Patient Saf · Mar 2006
SBAR: a shared mental model for improving communication between clinicians.
The importance of sharing a common mental model in communication prompted efforts to spread the use of the SBAR (Situation, Background, Assessment, and Recommendation) tool at OSF St. Joseph Medical Center, Bloomington, Illinois. ⋯ Staff adapted quickly to the use of SBAR, although hesitancy was noted in providing the "recommendation" to physicians. Medical staff were encouraged to listen for the SBAR components and encourage staff to share their recommendation if not initially provided.
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Jt Comm J Qual Patient Saf · Feb 2006
How many hospital pharmacy medication dispensing errors go undetected?
Hospital pharmacies dispense large numbers of medication doses for hospitalized patients. A study was conducted at an academic tertiary care hospital to characterize the incidence and severity of medication dispensing errors in a hospital pharmacy. ⋯ Given the volume of medications dispensed, even a low rate of drug distribution process translates into a large number of errors with potential to harm patients. Pharmacy distribution systems require further process redesign to achieve the highest possible level of safety and reliability.