RFID SHOWCASE

Fewer Events, Better Reporting

By Tom Inglesby

Patient safety event-reporting systems are found in all hospitals and are a mainstay of efforts to detect potentially critical events and quality problems. Initial reports usually come from the personnel directly involved in an event or the actions leading up to it, such as the nurse or physician caring for a patient when an error occurred, rather than management or patient safety professionals.

Health IT & Quality

Say No to Paper

By Barry P. Chaiken, MD, FHIMSS

Paper came one pill away from killing my 91-year-old mom. Only through luck did we dodge a medical error that could have extinguished a life that survived the Great Depression, World War II, polio epidemics, the birth of two children, the Cold War, the loss of her husband, and more than 60 years of employment. Up until her admission on May 7th, she had never experienced being an ill patient in a hospital.

ISMP

Heed This Warning! Don’t Miss Important Computer Alerts

By the Institute for Safe Medication Practices

Although pharmacists typically enter prescriptions and orders into the pharmacy computer, in some settings, specially trained pharmacy technicians or pharmacy interns perform this function. In these circumstances, a pharmacist later verifies that the order has been entered as prescribed at the same time he or she is assuring the appropriateness of the medication and verifying that the proper drug and dose has been prepared.

Barcode Technology for Positive Patient Identification Prior to Transfusion

Renewed initiative engages nurses and achieves 100% compliance. 

By Eileen L. Stone, BS, MT(ASCP), MS; Patricia Sherwood Keenan, RN, MSN, CPHQ, HACP

In today’s increasingly complex, highly demanding clinical environment, introducing a new technology is challenging under the best of circumstances. What if, right when roll-out is going well, an unrelated connectivity interruption leads nurses to conclude “this doesn’t work”? You need to get your initiative back on track—especially when it relates to improving the safety of a critically important patient-care process.

Design for Reliability: Barcoded Medication Administration

By Avis C. Hayden, PhD; Edward T. Lanoue, BSPharm, RPh; and Charles J. Still, MBA

There is now widespread agreement that hospital patients can be harmed by medication errors. Providing patients with medications in the acute care setting is a complex process that requires coordination in the flow of information when individuals order, transcribe, verify, dispense, and administer a medication. Early studies quantified the extent to which errors occur at each of these stages; one of the most troubling steps in the process is the administration phase, when 26 to 38% of the errors occur (Bates et al., 1995; Leape et al., 1995).