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Author: Lena Koers
Publisher:
ISBN:
Category :
Languages : en
Pages :
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Book Description
Introduction of a nationwide standardised coloured user-applied drug label for high-risk anaesthetic drugs.Background and goal of the study: Anaesthetic drug error is a recognised source of patient harm. Misidentification of drugs due to similar packaging or labelling is an important cause of drug error.1 Currently, there are no standardised labels for anaesthetic drugs in the Netherlands and many hospitals have their own colour-coding of anaesthetic drug labels.1 However, many anaesthesia providers are working in multiple hospitals. This increases the likelihood of drug error through misidentification of drugs by relying on the wrong colour scheme. We designed and implemented a standardised label for high-risk anaesthetic drugs in the Netherlands.Materials and methods: We designed the labels using the colours from the ISO standard, and the ISMP Tall Man Lettering system in order to reduce medication errors within the same group. A QR code for electronic registration and double check was added. The implementation process followed the implementation steps as described in the NICE guidence.2 u2028We send email notifications through the Dutch society of Anaesthesia and several national conferences were organised. A Prospective Risk Analysis was done. An e-learning was created to familiarise staff with the new labels. Results and discussion: The Academic Medical Centre Amsterdam was one of the pilot hospitals that started using the labels. The introductory e-learning was completed by 88% of staff. Ninety-four percent felt that the e-learning was helpful to explain the system behind the labels. A voluntary survey after using the labels was completed by 68 members of staff, and most common criticism was the likeness of certain colours, especially during scopic surgery as ambient light is switched to green. This problem was addressed and the colours were intensified. During the 3-month introduction period of the new labels, 7 minor drug errors were reported in 4715 anaesthetic actions. The Dutch Society for Anaesthesia now recommends the use of these labels nationwide.Conclusion: To reduce patient harm it is imperative to reduce anaesthetic drug error. We describe the successful design and implementation of standardised labels resulting in a nationwide recommendation to use these labels. The impact of standardised labels on patient outcomes has to be determined in future.References1. Preckel B et al. Labelverschillen leiden tot medicatiefouten. Med Contact 2014: 2345-7.2. How to put NICE guidance into practice. http://www.lumsa.it/sites/default/files/UTENTI/u492/nice.pdf.
Author: Lena Koers
Publisher:
ISBN:
Category :
Languages : en
Pages :
Get Book Here
Book Description
Introduction of a nationwide standardised coloured user-applied drug label for high-risk anaesthetic drugs.Background and goal of the study: Anaesthetic drug error is a recognised source of patient harm. Misidentification of drugs due to similar packaging or labelling is an important cause of drug error.1 Currently, there are no standardised labels for anaesthetic drugs in the Netherlands and many hospitals have their own colour-coding of anaesthetic drug labels.1 However, many anaesthesia providers are working in multiple hospitals. This increases the likelihood of drug error through misidentification of drugs by relying on the wrong colour scheme. We designed and implemented a standardised label for high-risk anaesthetic drugs in the Netherlands.Materials and methods: We designed the labels using the colours from the ISO standard, and the ISMP Tall Man Lettering system in order to reduce medication errors within the same group. A QR code for electronic registration and double check was added. The implementation process followed the implementation steps as described in the NICE guidence.2 u2028We send email notifications through the Dutch society of Anaesthesia and several national conferences were organised. A Prospective Risk Analysis was done. An e-learning was created to familiarise staff with the new labels. Results and discussion: The Academic Medical Centre Amsterdam was one of the pilot hospitals that started using the labels. The introductory e-learning was completed by 88% of staff. Ninety-four percent felt that the e-learning was helpful to explain the system behind the labels. A voluntary survey after using the labels was completed by 68 members of staff, and most common criticism was the likeness of certain colours, especially during scopic surgery as ambient light is switched to green. This problem was addressed and the colours were intensified. During the 3-month introduction period of the new labels, 7 minor drug errors were reported in 4715 anaesthetic actions. The Dutch Society for Anaesthesia now recommends the use of these labels nationwide.Conclusion: To reduce patient harm it is imperative to reduce anaesthetic drug error. We describe the successful design and implementation of standardised labels resulting in a nationwide recommendation to use these labels. The impact of standardised labels on patient outcomes has to be determined in future.References1. Preckel B et al. Labelverschillen leiden tot medicatiefouten. Med Contact 2014: 2345-7.2. How to put NICE guidance into practice. http://www.lumsa.it/sites/default/files/UTENTI/u492/nice.pdf.
Author: Institute of Medicine
Publisher: National Academies Press
ISBN: 0309101476
Category : Medical
Languages : en
Pages : 481
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Book Description
In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation's quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the seriesâ€"To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004)â€"this book sets forth an agenda for improving the safety of medication use. It begins by providing an overview of the system for drug development, regulation, distribution, and use. Preventing Medication Errors also examines the peer-reviewed literature on the incidence and the cost of medication errors and the effectiveness of error prevention strategies. Presenting data that will foster the reduction of medication errors, the book provides action agendas detailing the measures needed to improve the safety of medication use in both the short- and long-term. Patients, primary health care providers, health care organizations, purchasers of group health care, legislators, and those affiliated with providing medications and medication- related products and services will benefit from this guide to reducing medication errors.
Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309459575
Category : Medical
Languages : en
Pages : 483
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Book Description
Drug overdose, driven largely by overdose related to the use of opioids, is now the leading cause of unintentional injury death in the United States. The ongoing opioid crisis lies at the intersection of two public health challenges: reducing the burden of suffering from pain and containing the rising toll of the harms that can arise from the use of opioid medications. Chronic pain and opioid use disorder both represent complex human conditions affecting millions of Americans and causing untold disability and loss of function. In the context of the growing opioid problem, the U.S. Food and Drug Administration (FDA) launched an Opioids Action Plan in early 2016. As part of this plan, the FDA asked the National Academies of Sciences, Engineering, and Medicine to convene a committee to update the state of the science on pain research, care, and education and to identify actions the FDA and others can take to respond to the opioid epidemic, with a particular focus on informing FDA's development of a formal method for incorporating individual and societal considerations into its risk-benefit framework for opioid approval and monitoring.
Author: Michael Richard Cohen
Publisher: American Pharmacist Associa
ISBN: 1582120927
Category : Medical
Languages : en
Pages : 707
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Book Description
In this expanded 600+ page edition, Dr. Cohen brings together some 30 experts from pharmacy, medicine, nursing, and risk management to provide the most current thinking about the causes of medication errors and strategies to prevent them.
Author: Jan Ehrenwerth, MD
Publisher: Elsevier Health Sciences
ISBN: 0323112374
Category : Medical
Languages : en
Pages : 770
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Book Description
Anesthesia Equipment: Principles and Applications, 2nd Edition, by Dr. Jan Ehrenwerth and Dr. James B. Eisenkraft, offers expert, highly visual, practical guidance on the full range of delivery systems and technology used in practice today. It equips you with the objective, informed answers you need to ensure optimal patient safety. "This is a comprehensive, up-to-date reference textbook covering all aspects of physics and equipment for the modern American anaesthetist. It may be helpful to those studying for American fellowship examinations but is not suited to preparation for the UK FRCA examinations." Reviewed by: I.Wrench on behalf of the British Journal of Anaesthesia, Feb 2014 Make informed decisions by expanding your understanding of the physical principles of equipment, the rationale for its use, delivery systems for inhalational anesthesia, systems monitoring, hazards and safety features, maintenance and quality assurance, special situations/equipment for non-routine adult anesthesia, and future directions for the field. Ensure patient safety with detailed advice on risk management and medicolegal implications of equipment use. Apply the most complete and up-to-date information available on machines, vaporizers, ventilators, breathing systems, vigilance, ergonomics, and simulation. Visualize the safe and effective use of equipment thanks to hundreds of full-color line drawings and photographs. Access the complete text and images online, fully searchable, at www.expertconsult.com.
Author: Jonathan G. Hardman
Publisher: Oxford University Press
ISBN: 0199642044
Category : Medical
Languages : en
Pages : 1630
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Book Description
This new definitive resource addresses the fundamental principles of anaesthesia, underpinning sciences and the full spectrum of clinical anaesthetic practice. An international team of experts provide trustworthy, effective, and evidence-based guidance enabling clinicians to provide the very best clinical care to patients.
Author: Alan Merry
Publisher: Cambridge University Press
ISBN: 1009031163
Category : Medical
Languages : en
Pages : 304
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Book Description
With medication errors in healthcare an internationally recognised problem, this much-needed book delivers a comprehensive approach to understanding medication safety in the perioperative period. It reviews what medication adverse events are, and how often and where these errors occur, as well as exploring human cognitive psychology and explaining why things can go wrong at any time in a complex system. Detailed discussions around mistakes, judgement errors, slips and lapses, and violations, are presented alongside real-life examples of the indistinct line between negligence and inevitable error. The co-authors bring a wide and practical perspective to the theories and interventions that are available to improve medication safety, including legal and regulatory actions that further or impede safety. Essential reading for anesthesiologists, nurses, pharmacists and other perioperative team members committed to improving medication safety for their patients, and also an invaluable resource for those who fund, manage and regulate healthcare.
Author: Kerm Henriksen
Publisher:
ISBN:
Category : Medical
Languages : en
Pages : 526
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Book Description
v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.
Author: Alan Merry
Publisher:
ISBN: 9781108151702
Category :
Languages : en
Pages :
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Book Description
"Medication errors are the most common of all medical errors and pose a tremendous emotional and physical cost to patients and economic burden to our health system. The most reliable estimates of medication error in anesthesia place the rate at 1-2 in every 10 administrations, or 1 in every anesthetic. Most of the errors are harmless but other wreak devastation. These errors are a failure to plan well, or to carry out a well-designed plan; less talked about but perhaps more important are routine violations of best practices. Errors arise through fast and slow thinking; violations arise from a myriad of causes. There is an extensive body of expert consensus on how to improve medication safety, starting with an institutional commitment to improving medication safety, and ending with an individual practitioner committing to doing the right thing every time. Technical solutions, pharmacy solutions, standardization, and a safety culture are major themes in medication safety. Despite knowledge of what would make us safer, economic costs, a perceived lack of urgency, human resistance to change all conspire to medication safety difficult to achieve. Low-income countries face particular challenges in medication safety. Despite these challenges, we must dedicate ourselves anew to this goal - our patients deserve no less"--
Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309672104
Category : Medical
Languages : en
Pages : 427
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Book Description
Among the many who serve in the United States Armed Forces and who are deployed to distant locations around the world, myriad health threats are encountered. In addition to those associated with the disruption of their home life and potential for combat, they may face distinctive disease threats that are specific to the locations to which they are deployed. U.S. forces have been deployed many times over the years to areas in which malaria is endemic, including in parts of Afghanistan and Iraq. Department of Defense (DoD) policy requires that antimalarial drugs be issued and regimens adhered to for deployments to malaria-endemic areas. Policies directing which should be used as first and as second-line agents have evolved over time based on new data regarding adverse events or precautions for specific underlying health conditions, areas of deployment, and other operational factors At the request of the Veterans Administration, Assessment of Long-Term Health Effects of Antimalarial Drugs When Used for Prophylaxis assesses the scientific evidence regarding the potential for long-term health effects resulting from the use of antimalarial drugs that were approved by FDA or used by U.S. service members for malaria prophylaxis, with a focus on mefloquine, tafenoquine, and other antimalarial drugs that have been used by DoD in the past 25 years. This report offers conclusions based on available evidence regarding associations of persistent or latent adverse events.
