Medication Errors Attributed to Health Information Technology
Nearly 900 medication error reports listed health information technology (HIT) as a factor contributing to the event submitted to the Pennsylvania Patient Safety Authority. The most common HIT systems implicated in the events were the computerized prescriber order entry system, the pharmacy system, and the electronic medication administration record.
Dislodged Gastrointestinal Tubes: Prevention, Recognition, and Treatmen
Hospitals can decrease the risk for gastrointestinal tube complications by implementing best practices and risk reduction strategies to confirm proper positioning of gastrostomy tubes and to prevent, recognize, and manage dislodgement. Aside from peritonitis, sepsis, and death, other serious harm can result from even minor changes in gastrostomy tube position.
Handoff Communications: A Systems Approach
Handoffs are an integral part of care coordination and the delivery of safe patient care. Using handoff processes that incorporate critical thinking and reasoning skills to address patient needs and providing handoff training and education are strategies to improve patient handoff communications.
Retained Surgical Items: Events and Guidelines Revisited
Surgical items such as sponges, sharps, and instruments may be retained during surgery and can lead to serious patient harm. Detecting and reporting retained surgical items may help to determine patterns and root causes using a definition decided upon by the healthcare facility.