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Background: Incident reporting is widely used in hospitals to improve patient safety, but current reporting systems do not function optimally. The utility of incident reports is limited because hospital staff may not know what to report, may fear retaliation, and may doubt whether administrators will review reports and respond effectively. Methods: This is a clustered randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. The SAFE Loop has six key attributes: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will focus on medication errors and randomize 20 nursing units at a large academic/community hospital in Los Angeles. Outcomes include: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. Quantitative analyses will compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses will explore nurses' experiences with implementation. Conclusion: If effective, SAFE Loop will have several benefits: increasing nurses' engagement with reporting, producing more informative reports, enabling safety leaders to understand problems, designing system-based solutions more effectively, and lowering rates of high-priority patient safety events.
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We present technology enhancements that support the safe use of U-500 insulin.
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Using chloral hydrate carries a risk of adverse events and compounding errors, and much of the available literature recommends using alternative sedatives for pediatric patients. But evidence regarding the efficacy of chloral hydrate and of alternative agents is conflicting.
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Accidental IV administration of heparinized irrigation solution occurs frequently. Two cases from ISMP Canada offer some safe practice recommendations.
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Implementing IT in medication-use systems reduces adverse drug events by decreasing human error. But over-reliance on technology can lead to automation bias and complacency.
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Indication-based prescribing has many potential benefits, including preventing errors by reducing medication choices and assisting with medication reconciliation.
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The familiar but ambiguous sigs on prescriptions are often of limited help to patients and pharmacists. Sometimes, the instruction to "use as directed" has resulted in serious errors.
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Neuromuscular blockers have been inadvertently administered to patients who were not receiving proper ventilatory assistance, causing death or permanent injuries.
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Incorrectly prescribed medications can have serious implications, especially in young children. Safe practice recommendations include listing patients' age, weight, and date of birth on prescriptions, verifying discharge orders, and involving pharmacists in reconciliation.
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Leftover or improperly discarded drugs are easy prey for diversion and are fueling the opioid abuse epidemic. ISMP offers safe practice recommendations to prevent drug misuse.
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The final part of a 3-part series discusses medication safety risks related to labeling, patient education, and medication storage.
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Part 2 of a 3-part series discusses medication safety risks related to labeling, patient education, and medication storage.
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Part 1 of a 3-part series discusses 3 medication safety risks that can easily fall off the radar screen in hospitals and doctors' offices.
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Managing home infusion patients in the hospital and emergency department.
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Preventing incidents of oral meds given intravenously.
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Accidental overdoses involving fluorouracil infusions.
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Errors with flecainide suspension in children.
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Harm and death associated with methotrexate errors.
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Container mix-ups and syringe swaps in the surgical environment.
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The absence of a drug-disease interaction alert leads to a child's death.