RESUMO
BACKGROUND: Contributing factors to medication errors include distractions, lack of focus, and failure to follow standard operating procedures. The nursing unit is vulnerable to a multitude of interruptions and distractions that affect the working memory and the ability to focus during critical times. Methods that prevent these environmental effects on nurses can help avert medication errors. METHODS: A process improvement study examined the effects of standard protocols and visible signage within a hospital setting. The project was patterned after another study using similar techniques. Rapid Cycle Testing was used as one of the strategies for this process improvement project. Rapid Cycle Tests have become a part of the newly adopted Define, Measure, Analyze, Improve, and Control steps at this particular hospital. RESULTS: As a result, a medication administration check-list improved focus and standardized practice. Visible signage also reduced nurses' distractions and improved focus. CONCLUSION: The results provide evidence that protocol checklists and signage can be used as reminders to reduce distractions, and are simple, inexpensive tools for medication safety.
Assuntos
Atenção , Erros de Medicação/prevenção & controle , Recursos Humanos de Enfermagem Hospitalar , Gestão da Segurança/organização & administração , Adulto , Atitude do Pessoal de Saúde , Protocolos Clínicos , Ergonomia , Feminino , Fidelidade a Diretrizes/normas , Hábitos , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Relações Interprofissionais , Diretórios de Sinalização e Localização , Masculino , Erros de Medicação/métodos , Erros de Medicação/enfermagem , Memória , Pessoa de Meia-Idade , Pesquisa em Avaliação de Enfermagem , Recursos Humanos de Enfermagem Hospitalar/educação , Recursos Humanos de Enfermagem Hospitalar/organização & administração , Recursos Humanos de Enfermagem Hospitalar/psicologia , Cultura Organizacional , Avaliação de Processos e Resultados em Cuidados de Saúde , Guias de Prática Clínica como Assunto , Inquéritos e Questionários , Fatores de Tempo , Gestão da Qualidade Total/organização & administraçãoRESUMO
We describe a case of brachiocephalic fistula vein wall dissection (VWD) occurring in a 36-year-old female hemodialysis patient. Unlike subcutaneous or subfascial infiltrations for which the mechanism is blood extravasation, VWD seems to be due to disruption of the fistula vein layers caused by misplacement of the outflow (venous) needle bevel. In this setting, the pressure of the dialysis blood pump acts as the driving force of the dissecting column, extending it proximally. Gray-scale and color Doppler sonography proved to be very useful in the differential diagnosis of VWD, particularly with thrombosis of the fistula. Sonography also helped us decide when to resume cannulations.