Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-fscjk Total loading time: 0 Render date: 2024-12-24T19:02:18.101Z Has data issue: false hasContentIssue false

9 - Interventions to Improve Medication Safety

Published online by Cambridge University Press:  09 April 2021

Alan Merry  and
Joyce Wahr
Alan Merry
Affiliation:
University of Auckland
Joyce Wahr
Affiliation:
University of Minnesota
Get access

Summary

There are many expert-identified recommended interventions to improve medication safety: few have been rigorously tested and proven. Adoption of electronic medication processes can and has reduced medication error on the wards and in the OR. More recently, comprehensive patient safety programs have been shown to reduce medication errorsaw well as mortality. Reduction of human error in medicine will require a comprehensive bundle of interventions rather than any single silver bullet.There are many things that most institutions and practitioners could do today: each of these may make only a small difference but the key to substantially improving safety lies in the aggregation of minimal gains. Our patients have a right to expect greater investment into medication safety by health care institutions, and greater engagement with medication safety by the clinicians who care for them. Although their time in the OR is only part of the surgical patient's perioperative journey, it is an important part. Implementation of these recommendations should be a minimum expectation for institutions and anesthesia departments today, and is an excellent foundation from which initiatives to improve medication safety can be extended to the rest of the surgical pathway.

Keywords

Expert consensusrandomized controlled trialsElectronic health recordcompurterized order entryNew Paradigmpharmacy
Type
Chapter
Information
Medication Safety during Anesthesia and the Perioperative Period , pp. 156 - 190
Publisher: Cambridge University Press
Print publication year: 2021

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Miller, MR, Robinson, KA, Lubomski, LH, Rinke, ML, Pronovost, PJ. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care. 2007;16(2):116–126.Google Scholar
Singer, SJ, Gaba, DM, Falwell, A, et al. Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care. 2009;47(1):23–31.CrossRefGoogle ScholarPubMed
Pronovost, PJ, Holzmueller, CG, Martinez, E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32(2):102–108.Google ScholarPubMed
Gazarian, M, Graudins, LV. Long-term reduction in adverse drug events: an evidence-based improvement model. Pediatrics. 2012;129(5):e1334–42.Google Scholar
Breeding, J, Welch, S, Whittam, S,et al. Medication Error Minimization Scheme (MEMS) in an adult tertiary intensive care unit (ICU) 2009–2011. Aust Crit Care. 2013;26(2):58–75.Google Scholar
Keiffer, S, Marcum, G, Harrison, S, Teske, DW, Simsic, JM. Reduction of medication errors in a pediatric cardiothoracic intensive care unit. J Nurs Care Qual. 2015;30(3):212–219.Google Scholar
McClead, RE Jr, Catt, C, Davis, JT, et al. An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events. J Pediatr. 2014;165(6):1222–9.e1.Google Scholar
Durrand, JW, Batterham, AM, Danjoux, GR. Pre-habilitation. I: aggregation of marginal gains. Anaesthesia. 2014;69(5):403–406.Google Scholar
Prakash, V, Koczmara, C, Savage, P, et al. Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting. BMJ Qual Saf. 2014;23(11):884–892.Google Scholar
Moreira, ME, Hernandez, C, Stevens, AD, et al. Color-coded prefilled medication syringes decrease time to delivery and dosing error in simulated emergency department pediatric resuscitations. Ann Emerg Med. 2015;66(2):97–106.e3.Google Scholar
Merry, AF, Hannam, JA, Webster, CS, et al. Retesting the hypothesis of a clinical randomized controlled trial in a simulation environment to Validate Anesthesia Simulation in Error Research (the VASER Study). Anesthesiology. 2017;126(3):472–481.Google Scholar
Estock, JL, Murray, AW, Mizah, MT, et al. Label design affects medication safety in an operating room crisis: a controlled simulation study. J Patient Saf. 2018;14(2):101–106.CrossRefGoogle Scholar
Siebert, JN, Ehrler, F, Combescure, C, et al. A mobile device app to reduce time to drug delivery and medication errors during simulated pediatric cardiopulmonary resuscitation: a randomized controlled trial. J Med Internet Res. 2017;19(2):e31.CrossRefGoogle ScholarPubMed
Nuckols, TK, Smith-Spangler, C, Morton, SC, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Syst Rev. 2014;3:56.Google Scholar
Jensen, LS, Merry, AF, Webster, CS, Weller, J, Larsson, L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004;59(5):493–504.Google Scholar
Sackett, DL, Rosenberg, WM, Gray, JA, Haynes, RB, Richardson, WS. Evidence based medicine: what it is and what it isn't. Br Med J. 1996;312(7023):71–72.Google Scholar
Wahr, JA, Abernathy, JH 3rd, Lazarra, EH, et al. Medication safety in the operating room: literature and expert-based recommendations. Br J Anaesth. 2017;118(1):32–43.Google Scholar
Eichhorn, J. APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice. APSF Newsletter. 2010;25(1):1–7. Accessed January 3, 2020. https://www.apsf.org/article/apsf-hosts-medication-safety-conference/Google Scholar
Weick, KE, Sutcliffe, KM. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. 2nd ed. San Francisco, CA: Jossey-Bass; 2007.Google Scholar
Singer, SJ, Falwell, A, Gaba, DM, et al. Identifying organizational cultures that promote patient safety. Health Care Manage Rev. 2009;34(4):300–311.Google Scholar
Valentin, A, Schiffinger, M, Steyrer, J, Huber, C, Strunk, G. Safety climate reduces medication and dislodgement errors in routine intensive care practice. Intensive Care Med. 2013;39(3):391–398.Google Scholar
Singer, SJ, Vogus, TJ. Reducing hospital errors: interventions that build safety culture. Annu Rev Public Health. 2013;34:373–396.CrossRefGoogle ScholarPubMed
Frankel, AS, Leonard, MW, Denham, CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Serv Res. 2006;41(4 pt 2):1690–1709.CrossRefGoogle ScholarPubMed
Pronovost, PJ, Weast, B, Bishop, K, et al. Senior executive adopt-a-work unit: a model for safety improvement. Jt Comm J Qual Saf. 2004;30(2):59–68.Google Scholar
Committee on Data Standards for Patient Safety Board on Healthcare Services Institute of Medicine. Executive summary. In: Aspden, P, Corrigan, JM, Wolcott, J, Erikson, S, eds. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academies Press; 2004. Accessed July 18, 2020. https://www.ncbi.nlm.nih.gov/books/NBK216103Google Scholar
Brilli, RJ, McClead, RE Jr, Crandall, WV, et al. A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. J Pediatr. 2013;163(6):1638–1645.Google Scholar
Elden, NM, Ismail, A. The importance of medication errors reporting in improving the quality of clinical care services. Glob J Health Sci. 2016;8(8):243–251.Google Scholar
Pronovost, PJ, King, J, Holzmueller, CG, et al. A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). Jt Comm J Qual Patient Saf. 2006;32(3):119–129.Google Scholar
Berenholtz, SM, Hartsell, TL, Pronovost, PJ. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual. 2009;24(3):192–195.Google Scholar
Pronovost, P, Needham, D, Berenholtz, S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–2732.Google Scholar
Pronovost, PJ, Goeschel, CA, Colantuoni, E, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ. 2010;340:c309.CrossRefGoogle ScholarPubMed
Sexton, JB, Berenholtz, SM, Goeschel, CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39(5):934–939.Google Scholar
Deming, WE. The New Economics. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study; 1994.Google Scholar
Ramsay, AI, Turner, S, Cavell, G, et al. Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals. BMJ Qual Saf. 2014;23(2):136–146.Google Scholar
Bowdle, TA, Jelacic, S, Nair, B, et al. Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. Br J Anaesth. 2018;121(6):1338–1345.Google Scholar
Marx, D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Columbia University; 2001.Google Scholar
Haller, G, Myles, PS, Stoelwinder, J, et al. Integrating incident reporting into an electronic patient record system. J Am Med Inform Assoc. 2007;14(2):175–181.Google Scholar
Abstoss, KM, Shaw, BE, Owens, TA, et al. Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit. BMJ Qual Saf. 2011;20(11):914–922.Google Scholar
Frey, B, Buettiker, V, Hug, MI, et al. Does critical incident reporting contribute to medication error prevention? Eur J Pediatr. 2002;161(11):594–599.Google Scholar
Vincent, C, Taylor-Adams, S, Chapman, EJ, et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000;320(7237):777–781.Google Scholar
Wilbur, K, Scarborough, K. Medication safety huddles: teaming up to improve patient safety. Can J Hosp Pharm. 2005;58:151–155.Google Scholar
Morvay, S, Lewe, D, Stewart, B, et al. Medication event huddles: a tool for reducing adverse drug events. Jt Comm J Qual Patient Saf. 2014;40(1):39–45.Google Scholar
Hughes, RG, Blegen, MA. Medication administration safety. In: Hughes, RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. Accessed July 18, 2020. https://www.ncbi.nlm.nih.gov/books/NBK2656Google Scholar
2010–2021 Targeted Medication Safety Best Practices for Hospitals. Horsham, PA: Institute for Safe Medication Practices; 2018. Accessed July 18, 2020. https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for-Hospitalsv2.pdfGoogle Scholar
Nisly, S, Shiltz, ED, Vanarsdale, V, Laughlin, J. Implementation of an order set to adhere to national patient safety goals for warfarin therapy. Hosp Pharm. 2013;48(10):828–832.Google Scholar
Alper, SJ, Holden, RJ, Scanlon, MC, et al. Self-reported violations during medication administration in two paediatric hospitals. A systematic review of safety violations in industry. BMJ Qual Saf. 2012;21:408–415.Google Scholar
Trimble, AN, Bishop, B, Rampe, N. Medication errors associated with transition from insulin pens to insulin vials. Am J Health Syst Pharm. 2017;74(2):70–75.Google Scholar
Atherton, J. Development of the electronic health record. Virtual Mentor. 2011;13(3):186–189.Google ScholarPubMed
Gray, B, Johansen, I, Koch, S, Bowden, T. Electronic health records: an international perspective on “meaningful use.” Commonwealth Fund Newsletter. November 17, 2011:28. Accessed January 7, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2011/nov/electronic-health-records-international-perspective-meaningfulGoogle Scholar
Metzger, JB, Welebob, E, Turisco, F, Classen, DC. The Leapfrog Group's CPOE standard and evaluation tool. Patient Safety and Quality Healthcare Newsletter. July/August 2008. Accessed December 30, 2019. https://www.psqh.com/julaug08/cpoe.htmlGoogle Scholar
Guo, Y, Chung, P, Weiss, C, Veltri, K, Minamoto, GY. Customized order-entry sets can prevent antiretroviral prescribing errors: a novel opportunity for antimicrobial stewardship. P T. 2015;40(5):353–360.Google Scholar
Bates, DW, Leape, LL, Cullen, DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(15):1311–1316.CrossRefGoogle Scholar
Carayon, P, Du, S, Brown, R, et al. EHR-related medication errors in two ICUs. J Healthc Risk Manag. 2017;36(3):6–15.Google Scholar
Kadmon, G, Bron-Harlev, E, Nahum, E, et al.. Computerized order entry with limited decision support to prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935–940.Google Scholar
Gouyon, B, Iacobelli, S, Saliba, E, et al. A Computer Prescribing Order Entry-Clinical Decision Support system designed for neonatal care: results of the “preselected prescription” concept at the bedside. J Clin Pharm Ther. 2017;42(1):64–68.Google Scholar
Balasuriya, L, Vyles, D, Bakerman, P, et al. Computerized dose range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit. J Patient Saf. 2017;13(3):144–148.Google Scholar
Li, Q, Kirkendall, ES, Hall, ES, et al. Automated detection of medication administration errors in neonatal intensive care. J Biomed Inform. 2015;57:124–133.Google Scholar
Prgomet, M, Li, L, Niazkhani, Z, Georgiou, A, Westbrook, JI. Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. J Am Med Inform Assoc. 2017;24(2):413–422.Google Scholar
Senger, C, Kaltschmidt, J, Schmitt, SP, Pruszydlo, MG, Haefeli, WE. Misspellings in drug information system queries: characteristics of drug name spelling errors and strategies for their prevention. Int J Med Inform. 2010;79(12):832–839.Google Scholar
Vermeulen, KM, van Doormaal, JE, Zaal, RJ, et al. Cost-effectiveness of an electronic medication ordering system (CPOE/CDSS) in hospitalized patients. Int J Med Inform. 2014;83(8):572–580.Google Scholar
Nuckols, TK, Asch, SM, Patel, V, et al. Implementing computerized provider order entry in acute care hospitals in the United States could generate substantial savings to society. Jt Comm J Qual Patient Saf. 2015;41(8):341–350.Google Scholar
Gimenez-Manzorro, A, Romero-Jimenez, RM, Calleja-Hernandez, MA, et al.. Effectiveness of an electronic tool for medication reconciliation in a general surgery department. Int J Clin Pharm. 2015;37(1):159–167.Google Scholar
Rizzato Lede, DA, Benitez, SE, Mayan, JC 3rd, et al. Patient safety at transitions of care: use of a compulsory electronic reconciliation tool in an academic hospital. Stud Health Technol. 2015;216:232–236.Google Scholar
Pevnick, JM, Palmer, KA, Shane, R, et al. Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors. J Am Med Inform Assoc. 2016;23(5):942–950.Google Scholar
Health Quality and Safety Commission New Zealand. eMedRec brings number of benefits for Counties Manukau Health and Northland DHB. Med Saf. May 2, 2016. Accessed January 20, 2020. https://www.hqsc.govt.nz/our-programmes/medication-safety/news-and-events/news/2512/Google Scholar
Agrawal, A, Wu, WY. Reducing medication errors and improving systems reliability using an electronic medication reconciliation system. Jt Comm J Qual Patient Saf. 2009;35(2):106–114.Google Scholar
Grissinger, M. Safeguards for using and designing automated dispensing cabinets. P T. 2012;37(9):490–530.Google Scholar
Chapuis, C, Roustit, M, Bal, G, et al. Automated drug dispensing system reduces medication errors in an intensive care setting. Crit Care Med. 2010;38(12):2275–2281.Google Scholar
Tsao, NW, Lo, C, Babich, M, Shah, K, Bansback, NJ. Decentralized automated dispensing devices: systematic review of clinical and economic impacts in hospitals. Can J Hosp Pharm. 2014;67(2):138–148.Google Scholar
Cottney, A. Improving the safety and efficiency of nurse medication rounds through the introduction of an automated dispensing cabinet. BMJ Qual Improv Rep. 2014;3(1):u204237.w1843. doi:10.1136/bmjquality.u204237.w1843.Google Scholar
Institute for Safe Medication Practice. Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets. Horsham, PA: ISMP; 2008. Accessed April 14, 2018. https://www.ismp.org/Tools/guidelines/ADC_Guidelines_final.pdfGoogle Scholar
Poon, EG, Keohane, CA, Yoon, CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362(18):1698–1707.Google Scholar
Leape, LL, Bates, DW, Cullen, DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35–43.CrossRefGoogle ScholarPubMed
Poon, EG, Cina, JL, Churchill, W, et al. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med. 2006;145(6):426–434.Google Scholar
Shah, K, Lo, C, Babich, M, Tsao, NW, Bansback, NJ. Bar code medication administration technology: a systematic review of impact on patient safety when used with computerized prescriber order entry and automated dispensing devices. Can J Hosp Pharm. 2016;69(5):394–402.Google Scholar
Merry, AF, Webster, CS, Mathew, DJ. A new, safety-oriented, integrated drug administration and automated anesthesia record system. Anesth Analg. 2001;93(2):385–390.Google Scholar
Merry, AF, Webster, CS, Hannam, J, et al. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. BMJ. 2011;343:d5543.CrossRefGoogle ScholarPubMed
Jelacic, S, Bowdle, A, Nair, BG, et al. A system for anesthesia drug administration using barcode technology: the Codonics Safe Label System and Smart Anesthesia Manager. Anesth Analg. 2015;121(2):410–421.CrossRefGoogle ScholarPubMed
Douglas, JR Jr, Ritter, MJ. Implementation of an Anesthesia Information Management System (AIMS). Ochsner J. 2011;11(2):102–114.Google Scholar
Cooper, RL, Merry, A. Medication management. In: Stonemetz, J, Ruskin, K, eds. Anesthesia Informatics. Health Informatics Series. London: Springer; 2008:209–226.Google Scholar
Ohashi, K, Dalleur, O, Dykes, PC, Bates, DW. Benefits and risks of using smart pumps to reduce medication error rates: a systematic review. Drug Saf. 2014;37(12):1011–1020.Google Scholar
Nuckols, TK, Bower, AG, Paddock, SM, et al. Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events. J Gen Intern Med. 2008;23(suppl 1):41–45.Google Scholar
Borthwick, M, Woods, J, Keeling, S, Keeling, P, Waldmann, C. A survey to inform standardisation of intravenous medication concentrations in critical care. J Intensive Care Soc. 2007;8(1):92–96.Google Scholar
Hilmas, E, Sowan, A, Gaffoor, M, Vaidya, V. Implementation and evaluation of a comprehensive system to deliver pediatric continuous infusion medications with standardized concentrations. Am J Health Syst Pharm. 2010;67(1):58–69.CrossRefGoogle ScholarPubMed
Larsen, GY, Parker, HB, Cash, J, O'Connell, M, Grant, MC. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;116(1):e21–e25.Google Scholar
Tran, M, Ciarkowski, S, Wagner, D, Stevenson, JG. A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center. Jt Comm J Qual Patient Saf. 2012;38(3):112–119.Google Scholar
Irwin, D, Vaillancourt, R, Dalgleish, D, et al. Standard concentrations of high-alert drug infusions across paediatric acute care. Paediatr Child Health. 2008;13(5):371–376.Google Scholar
Merry, AF, Webster, CS, Connell, H. A new infusion syringe label system designed to reduce task complexity during drug preparation. Anaesthesia. 2007;62(5):486–491.Google Scholar
Kastrup, M, Balzer, F, Volk, T, Spies, C. Analysis of event logs from syringe pumps: a retrospective pilot study to assess possible effects of syringe pumps on safety in a university hospital critical care unit in Germany. Drug Saf. 2012;35(7):563–574.Google Scholar
Cook, TM, Payne, S, Skryabina, E, et al.. A simulation-based evaluation of two proposed alternatives to Luer devices for use in neuraxial anaesthesia. Anaesthesia. 2010;65(11):1069–1079.Google Scholar
Kinsella, SM, Goswami, A, Laxton, C, et al.. A clinical evaluation of four non-Luer spinal needle and syringe systems. Anaesthesia. 2012;67(11):1217–1224.Google Scholar
Australian Commission on Safety and Quality in Health Care. 2015 National Standard for User-Applied Labelling of Injectable Medicines, Fluids and Lines. Sydney: ACSQHC; 2015. Accessed January 11, 2020. https://www.safetyandquality.gov.au/our-work/medication-safety/safer-naming-labelling-and-packaging-medicines/national-standard-user-applied-labelling-injectable-medicines-fluids-and-linesGoogle Scholar
Hellier, E, Edworthy, J, Derbyshire, N, Costello, A. Considering the impact of medicine label design characteristics on patient safety. Ergonomics. 2006;49(5-6):617–630.Google Scholar
Zhong, W, Feinstein, JA, Patel, NS, Dai, D, Feudtner, C. Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years. BMJ Qual Saf. 2016;25(4):233–240.CrossRefGoogle ScholarPubMed
Lambert, BL, Schroeder, SR, Galanter, WL. Does Tall Man lettering prevent drug name confusion errors? Incomplete and conflicting evidence suggest need for definitive study. BMJ Qual Saf. 2016;25(4):213–217.Google Scholar
Emmerton, L, Rizk, MF, Bedford, G, Lalor, D. Systematic derivation of an Australian standard for Tall Man lettering to distinguish similar drug names. J Eval Clin Pract. 2015;21(1):85–90.Google Scholar
Webster, CS, Anderson, D, Murtagh, S. Safety and peri-operative medical care. Anaesthesia. 2001;56:496–497.Google Scholar
Webster, CS, Larsson, L, Frampton, CM, et al. Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study. Anaesthesia. 2010;65(5):490–499.Google Scholar
Standards New Zealand. User-Applied Labels for Use on Syringes Containing Drugs Used during Anaesthesia. Wellington: Standards New Zealand; 1996. AS/NZS 4375:1996. Accessed January 20, 2020. https://shop.standards.govt.nz/catalog/4375%3A1996%28AS%7CNZS%29/viewGoogle Scholar
CSA Group. Standard for User-Applied Drug Labels in Anaesthesia and Critical Care. Etobicoke, Canada: Canadian Standards Association; 1998. CAN/CSA-Z264.3-98. Accessed January 20, 2020. https://store.csagroup.org/ccrz__ProductDetails?sku=2700729Google Scholar
International Organization for Standardization. Anaesthetic and Respiratory Equipment – User-Applied Labels for Syringes Containing Drugs Used during Anaesthesia – Colours, Design and Performance. Geneva: International Organization for Standardization; 2008. ISO 26825:2008. Accessed January 20, 2020. https://www.iso.org/standard/43811.htmlGoogle Scholar
Russell, WJ. Getting into the red: a strategic step for safety. Qual Saf Health Care. 2002;11(1):107.Google Scholar
Rowe, D. Red plunger syringes for neuromuscular blocking drugs. Anaesthesia. 2015;70(1):107.Google Scholar
Fasting, S, Gisvold, SE. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anesth. 2000;47(11):1060–1067.Google Scholar
Orser, BA. Medication safety in anesthetic practice: first do no harm. Can J Anaesth. 2000;47(11):1051–1054.Google Scholar
Cheeseman, JF, Webster, CS, Pawley, MD, et al.. Use of a new task-relevant test to assess the effects of shift work and drug labelling formats on anesthesia trainees’ drug recognition and confirmation. Can J Anesth. 2011;58(1):38–47.Google Scholar
Pandit, JJ, Cook, TM. NAP5: Accidental Awareness during General Anaesthesia in the United Kingdom and Ireland: Report and Findings. London: National Audit Projects; 2014. Accessed January 20, 2020. https://www.nationalauditprojects.org.uk/NAP5home#ptGoogle Scholar
Grissinger, M. Color-coded syringes for anesthesia drugs-use with care. P T. 2012;37(4):199–201.Google Scholar
Rupp, SM. Color-coding of syringes may not enhance safety. Reg Anesth Pain Med. 2005;30(6):589–590.CrossRefGoogle Scholar
Webster, CS, Merry, AF. Colour coding, drug administration error and the systems approach to safety. Eur J Anaesthesiol. 2007;24(4):385–386.Google Scholar
American Society for Testing and Materials. Standard Specification for User Applied Drug Labels in Anesthesiology. Philadelphia: American Society for Testing and Materials; 1995. ASTM D4774-94. Accessed January 20, 2020. https://www.astm.org/DATABASE.CART/HISTORICAL/D4774-94.htmGoogle Scholar
Makwana, S, Basu, B, Makasana, Y, Dharamsi, A. Prefilled syringes: an innovation in parenteral packaging. Int J Pharm Invest. 2011;1(4):200–206.Google Scholar
Yang, Y, Rivera, AJ, Fortier, CR, Abernathy, JH 3rd. A human factors engineering study of the medication delivery process during an anesthetic: self-filled syringes versus prefilled syringes. Anesthesiology. 2016;124(4):795–803.Google Scholar
Royal Pharmaceutical Society. Professional Guidance on the Safe and Secure Handling of Medicines. London: Royal Pharmaceutical Society; 2018. Accessed November 16, 2019. https://www.rpharms.com/recognition/setting-professional-standards/safe-and-secure-handling-of-medicines/professional-guidance-on-the-safe-and-secure-handling-of-medicinesGoogle Scholar
Stucki, C, Sautter, AM, Wolff, A, Fleury-Souverain, S, Bonnabry, P. Accuracy of preparation of i.v. medication syringes for anesthesiology. Am J Health Syst Pharm. 2013;70(2):137–142.Google Scholar
Weeks, KW, Hutton, BM, Young, S, et al.. Safety in numbers 2: competency modelling and diagnostic error assessment in medication dosage calculation problem-solving. Nurse Educ Pract. 2013;13(2):e23–32.Google Scholar
Avidan, A, Levin, PD, Weissman, C, Gozal, Y. Anesthesiologists’ ability in calculating weight-based concentrations for pediatric drug infusions: an observational study. J Clin Anesth. 2014;26(4):276–280.Google Scholar
Venkataraman, A, Siu, E, Sadasivam, K. Paediatric electronic infusion calculator: an intervention to eliminate infusion errors in paediatric critical care. JICS. 2016;17(4):290–294.Google Scholar
Wheeler, DW, Degnan, BA, Sehmi, JS, et al. Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. Intensive Care Med. 2008;34(8):1441–1447.CrossRefGoogle Scholar
Australian and New Zealand College of Anaesthetists. Guidelines for the Safe Administration of Injectable Drugs in Anaesthesia. Melbourne: Australian and New Zealand College of Anaesthetists; 2017. Policy document PS 51. Accessed January 20, 2020. https://www.anzca.edu.au/resources/professional-documentsGoogle Scholar
Bond, CA, Raehl, CL, Franke, T. Medication errors in United States hospitals. Pharmacotherapy. 2001;21(9):1023–1036.Google Scholar
Bond, CA, Raehl, CL, Franke, T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. Pharmacotherapy. 2002;22(2):134–147.Google Scholar
Bond, CA, Raehl, CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy. 2006;26(6):735–747.Google Scholar
Bond, CA, Raehl, CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy. 2007;27(4):481–493.Google Scholar
Leguelinel-Blache, G, Arnaud, F, Bouvet, S, et al. Impact of admission medication reconciliation performed by clinical pharmacists on medication safety. Eur J Intern Med. 2014;25(9):808–814.Google Scholar
Smith, L, Mosley, J, Lott, S, et al. Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting. Pharm Pract. 2015;13(4):634.Google Scholar
Contreras Rey, MB, Arco Prados, Y, Sanchez Gomez, E. Analysis of the medication reconciliation process conducted at hospital admission. Farm Hosp. 2016;40(4):246–259.Google Scholar
Marinovic, I, Marusic, S, Mucalo, I, Mesaric, J, Bacic Vrca, V. Clinical pharmacist-led program on medication reconciliation implementation at hospital admission: experience of a single university hospital in Croatia. Croat Med J. 2016;57(6):572–581.Google Scholar
Mendes, AE, Lombardi, NF, Andrzejevski, VS, et al. Medication reconciliation at patient admission: a randomized controlled trial. Pharm Pract. 2016;14(1):656.Google Scholar
Allison, GM, Weigel, B, Holcroft, C. Does electronic medication reconciliation at hospital discharge decrease prescription medication errors? Int J Health Care Qual Assur. 2015;28(6):564–573.Google Scholar
Eisenhower, C. Impact of pharmacist-conducted medication reconciliation at discharge on readmissions of elderly patients with COPD. Ann Pharmacother. 2014;48(2):203–208.Google Scholar
Garcia-Molina Saez, C, Urbieta Sanz, E, Madrigal de Torres, M, Vicente Vera, T, Perez Carceles, MD. Computerized pharmaceutical intervention to reduce reconciliation errors at hospital discharge in Spain: an interrupted time-series study. J Clin Pharm Ther. 2016;41(2):203–208.Google Scholar
Musgrave, CR, Pilch, NA, Taber, DJ, et al. Improving transplant patient safety through pharmacist discharge medication reconciliation. Am J Transplant. 2013;13(3):796–801.Google Scholar
Pourrat, X, Corneau, H, Floch, S, et al. Communication between community and hospital pharmacists: impact on medication reconciliation at admission. Int J Clin Pharm. 2013;35(4):656–663.Google Scholar
Bishop, MA, Cohen, BA, Billings, LK, Thomas, EV. Reducing errors through discharge medication reconciliation by pharmacy services. Am J Health Syst Pharm. 2015;72(17 suppl 2):S120–S126.Google Scholar
Ensing, HT, Stuijt, CC, van den Bemt, BJ, et al. Identifying the optimal role for pharmacists in care transitions: a systematic review. J Manag Care Spec Pharm. 2015;21(8):614–636.Google Scholar
Mekonnen, AB, McLachlan, AJ, Brien, JA. Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis. J Clin Pharm Ther. 2016;41(2):128–144.Google Scholar
Anderegg, SV, Wilkinson, ST, Couldry, RJ, Grauer, DW, Howser, E. Effects of a hospitalwide pharmacy practice model change on readmission and return to emergency department rates. Am J Health Syst Pharm. 2014;71(17):1469–1479.CrossRefGoogle ScholarPubMed
Sebaaly, J, Parsons, LB, Pilch, NA, et al.. Clinical and financial impact of pharmacist involvement in discharge medication reconciliation at an academic medical center: a prospective pilot study. Hosp Pharm. 2015;50(6):505–513.Google Scholar
Leape, LL, Cullen, DJ, Clapp, MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282(3):267–270.Google Scholar
Samaranayake, NR, Cheung, ST, Chui, WC, Cheung, BM. The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong. Int J Clin Pharm. 2013;35(3):432–438.Google Scholar
Galanter, W, Falck, S, Burns, M, Laragh, M, Lambert, BL. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). J Am Med Inform Assoc. 2013;20(3):477–481.Google Scholar
Rudall, N, McKenzie, C, Landa, J, et al. PROTECTED-UK – Clinical pharmacist interventions in the UK critical care unit: exploration of relationship between intervention, service characteristics and experience level. Int J Pharm Pract. 2017;25(4):311–319.CrossRefGoogle ScholarPubMed
Shulman, R, McKenzie, CA, Landa, J, et al.. Pharmacist’s review and outcomes: treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK). J Crit Care. 2015;30(4):808–813.Google Scholar
Richter, A, Bates, I, Thacker, M, et al. Impact of the introduction of a specialist critical care pharmacist on the level of pharmaceutical care provided to the critical care unit. Int J Pharm Pract. 2016;24(4):253–261.CrossRefGoogle Scholar
Shaw, RE, Litman, RS. Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States. Jt Comm J Qual Patient Saf. 2014;40(10):471–475.Google ScholarPubMed
Fiala, D, Grady, KP, Smigla, R. Continued cost justification of an operating room satellite pharmacy. Am J Hosp Pharm. 1993;50(3):467–469.Google Scholar
Thomas, JA, Martin, V, Frank, S. Improving pharmacy supply-chain management in the operating room. Healthc Financ Manage. 2000;54(12):58–61.Google Scholar
Ziter, CA, Dennis, BW, Shoup, LK. Justification of an operating-room satellite pharmacy. Am J Hosp Pharm. 1989;46(7):1353–1361.Google Scholar
Wahr, JA, Merry, AF. Medication errors in the perioperative setting. Curr Anesthesiol Rep. 2017;7(3):320–329.Google Scholar
Leonard, M, Graham, S, Bonacum, D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):i85–90.Google Scholar
Greenberg, CC, Regenbogen, SE, Studdert, DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204(4):533–540.Google Scholar
Gawande, AA, Thomas, EJ, Zinner, MJ, Brennan, TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126(1):66–75.Google Scholar
ElBardissi, AW, Regenbogen, SE, Greenberg, CC, et al. Communication practices on 4 Harvard surgical services: a surgical safety collaborative. Ann Surg. 2009;250(6):861–865.Google Scholar
Nagpal, K, Vats, A, Lamb, B, et al. Information transfer and communication in surgery: a systematic review. Ann Surg. 2010;252(2):225–239.Google Scholar
Nagpal, K, Vats, A, Ahmed, K, et al. A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg. 2010;145(6):582–588.Google Scholar
Neily, J, Mills, PD, Young-Xu, Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693–1700.Google Scholar
Hull, L, Arora, S, Aggarwal, R, et al. The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg. 2012;214(2):214–230.CrossRefGoogle Scholar
Mishra, A, Catchpole, K, Dale, T, McCulloch, P. The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc. 2008;22(1):68–73.Google Scholar
Carney, BT, West, P, Neily, J, Mills, PD, Bagian, JP. Changing perceptions of safety climate in the operating room with the Veterans Health Administration medical team training program. Am J Med Qual. 2011;26(3):181–184.Google Scholar
Awad, SS, Fagan, SP, Bellows, C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770–774.Google Scholar
Armour Forse, R, Bramble, JD, McQuillan, R. Team training can improve operating room performance. Surgery. 2011;150(4):771–778.Google Scholar
Santos, R, Bakero, L, Franco, P, et al.. Characterization of non-technical skills in paediatric cardiac surgery: communication patterns. Eur J Cardiothorac Surg. 2012;41(5):1005–1012.Google Scholar
Weller, J, Morris, R, Watterson, L, et al. Effective management of anaesthetic crises: development and evaluation of a college-accredited simulation-based course for anaesthesia education in Australia and New Zealand. Simul Healthc. 2006;1(4):209–214.Google Scholar
Weller, J, Cumin, D, Torrie, J, et al. Multidisciplinary operating room simulation-based team training to reduce treatment errors: a feasibility study in New Zealand hospitals. N Z Med J. 2015;128(1418):40–51.Google Scholar
Patanwala, AE, Sanders, AB, Thomas, MC, et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Ann Emerg Med. 2012;59(5):369–373.Google Scholar
Rask, K, Culler, S, Scott, T, et al. Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation. J Hosp Med. 2007;2(4):212–218.Google Scholar
Nundy, S, Mukherjee, A, Sexton, JB, et al. Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg. 2008;143(11):1068–1072.Google Scholar
Einav, Y, Gopher, D, Kara, I, et al. Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. Chest. 2010;137(2):443–449.Google Scholar
Haynes, AB, Weiser, TG, Berry, WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–499.Google Scholar
de Vries, EN, Prins, HA, Crolla, RMPH, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928–1937.Google Scholar
Paull, DE, Mazzia, LM, Wood, SD, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg. 2010;200(5):620–623.Google Scholar
Lingard, L, Regehr, G, Cartmill, C, et al. Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice. BMJ Qual Saf. 2011;20(6):475–482.Google Scholar
Hudson, CC, McDonald, B, Hudson, JK, Tran, D, Boodhwani, M. Impact of anesthetic handover on mortality and morbidity in cardiac surgery: a cohort study. J Cardiothorac Vasc Anesth. 2015;29(1):11–16.Google Scholar
Saager, L, Hesler, BD, You, J, et al. Intraoperative transitions of anesthesia care and postoperative adverse outcomes. Anesthesiology. 2014;121(4):695–706.Google Scholar
Joy, BF, Elliott, E, Hardy, C, et al.. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011;12(3):304–308.Google Scholar
Petrovic, MA, Aboumatar, H, Baumgartner, WA, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth. 2012;26(1):11–16.Google Scholar
Wayne, JD, Tyagi, R, Reinhardt, G, et al. Simple standardized patient handoff system that increases accuracy and completeness. J Surg Educ. 2008;65(6):476–485.Google Scholar
Skaugset, LM, Farrell, S, Carney, M, et al. Can you multitask? Evidence and limitations of task switching and multitasking in emergency medicine. Ann Emerg Med. 2016;68(2):189–195.Google Scholar
Dreher, JC, Koechlin, E, Ali, SO, Grafman, J. The roles of timing and task order during task switching. Neuroimage. 2002;17(1):95–109.Google Scholar
Reason, J. Human Error. New York, NY: Cambridge University Press; 1990.Google Scholar
Wimpenny, P, Kirkpatrick, P. Roles and systems for routine medication administration to prevent medication errors in hospital-based, acute care settings: a systematic review. JBI Libr Syst Rev. 2010;8(10):405–446.Google Scholar
Whitman, GR, Kim, Y, Davidson, LJ, Wolf, GA, Wang, SL. The impact of staffing on patient outcomes across specialty units. J Nurs Adm. 2002;32(12):633–639.Google Scholar
Picone, DM, Titler, MG, Dochterman, J, et al. Predictors of medication errors among elderly hospitalized patients. Am J Med Qual. 2008;23(2):115–127.Google Scholar
Jones, S, Blake, S, Hamblin, R, et al.. Reducing harm from falls. N Z Med J. 2016;129(1446):89–103.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×