Skip to main content Accessibility help
×
Hostname: page-component-cd9895bd7-jkksz Total loading time: 0 Render date: 2024-12-27T18:27:50.703Z Has data issue: false hasContentIssue false

Chapter 10 - Medication Safety at a Pediatric Hospital and Failure Modes Effects Analysis: A Series of Projects Undertaken to Address the Issue of Medication Errors in the Operating Room

from Section 4 - Putting Tools into Practice

Published online by Cambridge University Press:  27 July 2023

Sally E. Rampersad
Affiliation:
University of Washington School of Medicine, Seattle
Cindy B. Katz
Affiliation:
Seattle Children’s Hospital, Washington
Get access

Summary

YTR Blurb

Type
Chapter
Information
Publisher: Cambridge University Press
Print publication year: 2023

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

Cheng, CH, Chou, CJ, Wang, PC, et al. Applying HFMEA to prevent chemotherapy errors. Journal of Medical Systems. 2012;36(3):15431551.CrossRefGoogle Scholar
van Tilburg, CM, Leistikow, IP, Rademaker, CM, et al. Health care failure mode and effect analysis: A useful proactive risk analysis in a pediatric oncology ward. Quality and Safety in Health Care. 2006;15(1):5863.CrossRefGoogle Scholar
Rosen, MA, Sampson, JB, Jackson, EV, Jr., et al. Failure mode and effects analysis of the universal anaesthesia machine in two tertiary care hospitals in Sierra Leone. British Journal of Anaesthesia. 2014;113(3):410415.CrossRefGoogle Scholar
Chang, DS, Chung, JH, Sun, KL, et al. A novel approach for evaluating the risk of health care failure modes. Journal of Medical Systems. 2012;36(6):39673974.CrossRefGoogle Scholar
DeRosier, J, Stalhandske, E, Bagian, JP, et al. Using health care failure mode and effect analysis: The VA National Center for patient safety’s prospective risk analysis system. Joint Commission Journal on Quality and Patient Safety. 2002;28(5):248–267, 209.Google Scholar
Chatman, I, ed., Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction. Oakbrook, IL, The Joint Commission, 2010.Google Scholar
Institute of Medicine CoQHCiA. To Err Is Human, Building a Safer Health System. Washington, D.C., Report of the Institute of Medicine, 2000.Google Scholar
Abeysekera, A, Bergman, IJ, Kluger, MT, and Short, TG. Drug error in anaesthetic practice: A review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia. 2005;60(3):220227.CrossRefGoogle Scholar
Llewellyn, RL, Gordon, PC, Wheatcroft, D, Lines, D, Reed, A, Butt, AD, et al. Drug administration errors: A prospective survey from three South African teaching hospitals. Anaesthesia and Intensive Care. 2009;37(1):9398.CrossRefGoogle Scholar
Orser, BA Cohen, DU and Cohen, DUMR. Perioperative medication errors: Building safer systems. Anesthesiology. 2016;124(1):13.CrossRefGoogle Scholar
Tyler, D. A Wake Up Safe Patient Safety Alert, Decreasing the Risks of Intravenous Medication Errors. Wake Up Safe 2010. Available at https://wakeupsafe.org/safety_alerts/157/ (Accessed 7/24/22).Google Scholar
Conroy, S, Sweis, D, Planner, C, Yeung, V, Collier, J, Haines, L, et al. Interventions to reduce dosing errors in children: A Systematic review of the literature. Drug Safety. 2007;30(12):11111125.CrossRefGoogle Scholar
Merry, AF and Anderson, BJ. Medication errors – New approaches to prevention. Paediatric Anaesthesia. 2011;21(7):743753.Google Scholar
Stucky, ER. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112(2):431436.Google Scholar
Cote, CJ, Karl, HW, Notterman, DA, Weinberg, JA, and McCloskey, C. Adverse sedation events in pediatrics: Analysis of medications used for sedation. Pediatrics. 2000;106(4):633644.CrossRefGoogle Scholar
Paix, AD, Bullock, MF, Runciman, WB, and Williamson, JA. Crisis management during anaesthesia: Problems associated with drug administration during anaesthesia. Quality and Safety in Health Care. 2005;14(3):e15.CrossRefGoogle Scholar
Eichhorn, J. ASPF Hosts Medication Safety Conference, Consensus Group Defines Challenges and Opportunities for Improved Practice. [updated Spring 2010; cited 2016 December]. 1,3–8]. Available from: http://apsf.org/newsletters/html/2010/spring/index.htm (Accessed 10/14/2020).Google Scholar
ISMP. Key Vulnerabilities in the Surgical Environment: Container Mix-Ups and Syringe Swaps 2015 [cited 2016 December]. Available from: www.ismp.org/newsletters/acutecare/showarticle.aspx?id=123 (Accessed 10/14/2020).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):493504.CrossRefGoogle Scholar
Merry, AF, Webster, CS, Hannam, J, Mitchell, SJ, Henderson, R, Reid, P, 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 Scholar
ISMP. ISMP’s list of High-Alert Medications 2012. Available from: www.ismp.org.**Google Scholar
Snyder, RA, Abarca, J, Meza, JL, Rothschild, JM, Rizos, A, and Bates, DW. Reliability Evaluation of the Adapted National Coordinating Council Medication Error Reporting and Prevention (NCC MERP) index. Pharmacoepidemiology Drug Safety. 2007;16(9):10061013.CrossRefGoogle Scholar
Chatman, I, ed. Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction. 3rd ed., Oakbrook, IL, The Joint Commission, 2010.Google Scholar
DeRosier, J, Stalhandske, E, Bagian, JP, and Nudell, T. Using health care failure mode and effect analysis: The VA National Center for patient safety’s prospective risk analysis system. Joint Commission Journal Quality Improvement. 2002;28(5):248–267, 09.Google Scholar
Perla, RJ, Provost, LP, and Murray, SK. The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality and Safety. 2011;20(1):4651.Google Scholar
Byrne, AJ, Oliver, M, Bodger, O, Barnett, WA, Williams, D, Jones, H, et al. Novel method of measuring the mental workload of anaesthetists during clinical practice. British Journal of Anaesthesia. 2010;105(6):767771.CrossRefGoogle Scholar
Ross, V, Jongen, EM, Wang, W, Brijs, T, Brijs, K, Ruiter, RA, et al. Investigating the influence of working memory capacity when driving behavior is combined with cognitive load: An LCT study of young novice drivers. Accident Analysis Prevention. 2014;62:377387.CrossRefGoogle Scholar
Grigg, E, Martin, LD, Ross, F, Roesler, A, Rampersad, S, Haberkern, C, Low, D, Carlin, K, Martin, L. Assessing the impact of the anesthesia medication template on medication errors during anesthesia: A prospective study. Anesthesia and Analgesia. May 2017;124(5):1617–1625.Google Scholar
Yang, Y, Rivera, AJ, Fortier, CR, and 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):795803.CrossRefGoogle Scholar
Flynn, EA, Barker, KN, Pepper GA, Bates DW, and Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. American Journal of Health System Pharmacy. 2002;59(5):436446.CrossRefGoogle Scholar
Runciman, B, Merry, A, and Smith, AM. Improving patients’ safety by gathering information. Anonymous reporting has an important role. BMJ. 2001;323(7308):298.CrossRefGoogle Scholar
Banja, J. The normalization of deviance in healthcare delivery. Business Horizons. 2010;53(2):139.CrossRefGoogle Scholar
Nanji, KC, Patel, A, Shaikh, S, Seger, DL, and Bates, DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124(1):2534.Google Scholar
Jelacic, S, Bowdle, A, Nair, BG, Kusulos, D, Bower, L, and Togashi, K. A system for anesthesia drug administration using barcode technology: The Codonics safe label system and smart anesthesia manager. Anesthesia and Analgesia. 2015;121(2):410421.Google Scholar
Webster, CS, Larsson, L, Frampton, CM, Weller, J, McKenzie, A, Cumin, D, et al. Clinical assessment of a new anaesthetic Drug Administration System: A prospective, controlled, longitudinal incident monitoring study. Anaesthesia. 2010;65(5):490499.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
×