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According to the Institute of Medicine report, titled “To Err Is Human: Building a Safer Health System”, it was first reported in 1999 that between 44,000 and 98,000 Americans die in hospitals each year due to mistakes in their care. Get Consumer Updates by E-mail Consumer Updates RSS Feed Share copies of this article (246 KB) On this page Sharing Error Reports How to Protect Yourself What is the Food and Drug Administration (FDA) doing to help protect consumers from medication errors? Note: If you need help accessing information in different file formats, see Instructions for Downloading Viewers and Players. According to the 1999 Institute of Medicine report, “To Err is Human”, an estimated 98,000 patients die each year from medical errors. The Near Miss Reporting System was begun in 2007 by the New York Chapter of the American College of Physicians and is funded by the NYS Dept of Health (DOH). Initially the project focused on reporting from internal medicine residents only, but this summer it is expanding to include all residency training programs in New York State.
CIR has been a member of the Near Miss Advisory Committee since 2007, along with representatives from the NYSDOH, Greater New York Hospital Association, the Hospital Association of New York State and others. We are looking for residents who want to learn more about the Near Miss project and help establish it in your own hospital.  Completion of the two hour training program will result in certification which may be used towards ACGME competency in Practice Based Learning and Improvement, Professionalism and System Based Practice. For more information, please visit the NYACP Near Miss Project website and stay tuned to the CIR website for upcoming Near Miss training sessions. ABSTRACTDespite the fact that HYDROmorphone (Dilaudid®) is widely used, there appear to be gaps in understanding its efficacy and potency, which can lead to serious medication errors. Share176 Tweet1 Pin24 Reddit EmailPrescription writing is something that I used to worry so much about in my 3rd year of medical school.
While these are just estimates from various studies and statistical models, the numbers are staggering. A prescription is an order that is written by you, the physician (or medical student with signature by a physician) to tell the pharmacist what medication you want your patient to take.
According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) national patient safety goals, at least two patient identifiers should be used in various clinical situations. The last instruction on the prescription informs the pharmacist how many times the patient will be allowed to use the same exact prescription, i.e.
This example shows a common way to write prescriptions for liquids, especially for children.
DisclosureThis website contains links and references to products and services that may include affiliates, sponsorships, or other business relationships in which The Medical School Headquarters may receive compensation from referrals or sales actions. Industry leading EMR software for physical therapists fully integrated with billing, scheduling and more.
The number one priority of our system is that it is highly customizable while still being easy to use. Our physical therapy management software is an entire electronic medical office that provides file and office management solutions to help you focus on the most important aspect of your work: helping patients.
Our physical therapy EHR software provides cost-effective, time-saving solutions to your file management needs. Our EHR is delivered fully configured to your physical therapy practice in a ready-to-go state, limiting the customization that you need to do to get started. Letter writing is a time-consuming task that most physical therapy clinics must perform on a daily basis.
Our physical therapy practice management software is the industry leader for physical therapists because of its thoughtful integration with essential office management modules. The scheduling module works with other modules to allow easy access to information such as patient account balances, co-payments, patient demographics, visit notes, prescriptions, alerts, reminders, notes, and more. Conducting a thorough patient assessment is critical for ensuring that we get the most clinical information from our patients. As mentioned above, you can get a free resource on the subject of conducting a medical assessment that is still very valid for nurses as well as doctors.
The books cover the reasons why we assess a patient, factors that affect patient assessments and how to perform one. We go in-depth into neurological assessments and include topics such as mental status, cranial nerves and their assessment, motor function, reflexes, sensation, arousal, attention and concentration, memory, language, visual spacial perception, praxis and much more. Here at E Advanced Healthcare we believe that healthcare education is a right and should not be made either complicated, inaccessible or expensive.
As you have read this far down the page, I am going to give you a sneak peak of the book itself. My experience in healthcare is mostly within critical care, however I also have extensive experience of working in ward environments. Patient assessments are necessary to gain a baseline evaluation of the patient’s clinical condition in order to aim our treatments towards a positive change, improved care and an expedited discharge from our care.
Patient assessments are the most important skill any healthcare professional can learn as these assessments are the basis of all the decisions that we make regarding the care we provide for our patients.
By undertaking patient assessments we are able to prioritise our care so that the most urgent need  gets attended to first.
These assessments start very generalised, but as issues are identified the assessments begin to focus in greater detail on the smaller and more precise issues that the patient is presenting or complaining of. This can be improved upon by providing education and mentorship into how to prioritise care.
Assessment education is also often needed, which again is normally learnt during our training, however when working in new environments clinical supervision and mentorship will help the clinician thoroughly assess their patients. There are many risk scoring tools that we use in our industry, for example in the nursing field there is the Waterlow score for the risk of pressure areas developing with the patient. Communicating and handing over care effectively will help us relay our assessments onto the rest of the multidisciplinary team so that our observations can be attended to by the necessary personnel.
There are many other assessment tools available in the workplace regarding patient assessments.
Australia has recently been working very hard to establish the correct number of nursing staff for patients they are caring for. Medical opinion has always been regarded as superior to any other speciality in healthcare, however times are changing and more emphasis is being put into the value of other members of the multidisciplinary team. Performing a thorough patient assessment needs to be completed in a systematic manner, so that all areas are covered and nothing is missed. Before entering the patient’s area we need to adhere to what is commonly known as the “five moments of hand hygiene”. In keeping with the five moments of hand hygiene: putting on personal protective equipment is also necessary.
To assess the patient we need to approach them, however as with advanced life support training it is essential that we assess if it is safe to approach.
Once we have approached them we need to explain to the patient that we are going to perform an assessment. Medications such as opiates, benzodiazepines, anti-psychotics, antidepressants or other sedatives.
This list is extensive and is not fully inclusive, it just demonstrates the wide scope of causes for a decrease in level of consciousness[2]. To make a thorough neurological assessment of the patient we need to assess the patient’s Glasgow Coma Scale, which is a scale ranging from 3 – 15.
Painful stimuli appears a cruel thing to do to a patient who we are supposed to be caring for, however providing this stimuli if the patient does not respond is the only way that we can really tell if there is a severe problem occurring when undertaking our medical assessments.
If painful stimuli is applied peripherally then a spinal reflex may occur, which is when the stimulus passes up the afferent pathway and arcs at the spinal cord, passing back down the efferent pathway without ever reaching the brain.
A torch light should be shone into the patient’s eyes to hopefully observe a pupillary constriction. Assess their ability to comprehend and follow a complex command, whilst not helping them achieve this.
If you like what you have just read, please get your copy of either the e-book version of the patient assessment resource or purchase the paperback version.
Modern clinical laboratories around the world are now enjoying the benefit of decades of development in analytical hardware, assay methodology and reagent systems. For many years however, there has been increasing recognition that the situation is less favourable in the preanalytical phase of the testing process such that there is now general acceptance of the need to focus on improvements in this area. Quality improvement in the preanalytical phase helps laboratories to provide more timely and accurate test results for clinicians ' crucial factors in terms of patient outcome and healthcare institution operating costs. In this article, we examine common causes of sub-optimal specimen quality, the implications for test result error and the steps that can be taken to overcome these problems whilst achieving consistently safe and efficient specimen collection with good test turn around time (TAT). Before moving to a discussion on sub-optimal specimens, we should define what we mean by a 'quality specimen'.
The worst type of preanalytical error is when the physician receives and acts on test results from the wrong patient. Inadequate flushing of the IV line is a common cause of contamination of specimens with electrolytes, glucose or other substances causing laboratory error.
After flushing, a discard syringe (minimum 3 - 5 mL) or discard evacuated tube (again minimum 3 - 5 mL) should be obtained prior to collecting blood for analysis.
When the closed evacuated collection system is used for collection of a variety of tubes (with different additives) from one patient, it is important to fill the tubes in an order which minimizes any adverse effect on specimen quality due to the additive from the preceding tube.
It is recommended that the tourniquet be removed when blood begins to flow into the first tube.
Blood cells in general and red blood cells in particular are fragile and susceptible to rupture due to mechanical trauma (as above), osmotic shock (exposure to non-isotonic fluids) and exposure to temperature extremes (e.g. Care, therefore, needs to be taken when collecting specimens to avoid mechanical trauma to the cells. Hemolysis is least likely to occur in specimens collected via venipuncture using a closed, evacuated collection system.
Where these are used, it is important that the blood is allowed to be drawn into the tube by the vacuum in the tube. As for hemolyzed specimens, overtly clotted specimens and those with micro-clots are, unfortunately, commonplace in the clinical laboratory. Mixing is just as important for serum and serum gel tube specimens containing a clot activator. The single most effective way to reduce TAT for clinical chemistry results is the use of heparin plasma specimens in lieu of serum. Apart from the five most common problem areas we have covered above, three other frequent sources of sub-optimal specimen quality seen in ED are those associated with blood gas analysis, blood culture and urine specimens.
Whilst the concentration of heparin in most blood gas syringes is much higher than in evacuated blood collection tubes, clotted specimens are a key issue and lead to increased TAT and increased blood gas analyzer downtime.
Most modern syringes contain an electrolyte balanced heparin additive designed to be compatible with all electrolyte assays (including ionized calcium and ionized magnesium). As for blood gas specimens, collection of blood culture specimens presents a significant risk of NSI in ED. If additional blood is required, the bottle can then be re-engaged in the holder assembly attached to the winged collection set. We hope the information presented above helps to provide an understanding of the key issues pertaining to specimen quality (and therefore test result accuracy), safety and TAT in the ED. Brian Smith is Clinical Director for Asia Pacific and Japan, BD Diagnostics — Preanalytical Systems in Australia. For questions regarding our Blood, Urine collection, or other sample collection products and services please contact us. This publication is a service to the customers and friends of BD, and is designed only to provide general information. As humans we are always susceptible to make errors, but understanding why we make them will help us design systems that decrease the chances of such errors to happen.
Eg: The nurse is distracted in her busy shift and gives a medication to her patient which was intended for another patient.
The rule based errors or cognitive errors are very interesting and if you wish to learn more then refer to this brief article by Dr. Latent Errors :   Latent errors are accidents waiting to happen because of defects in the design of the system. FDA’s Center for Drug Evaluation and Research (CDER) has formalized a long standing relationship with the Institute for Safe Medication Practices (ISMP) a non-profit organization based in Horsham, Pa.
Data is collected through an on-line, voluntary, confidential and anonymous reporting system.
Analysts reviewed medication errors and adverse drug reactions (ADR) involving HYDROmorphone that were reported to the Pennsylvania Patient Safety Authority. Even though I don’t think I caused any major harm to any of my patients with prescription errors, I wish that I had read something like this when I first started writing prescriptions when I was in my 3rd year of medical school.
The basic format of a prescription includes the patient’s name and another patient identifier, usually the date of birth.
Unfortunately when you are in a hurry and scribbling these prescriptions, (there is a truth behind never being able to read a physician’s hand writing) many of these abbreviations can look similar.
This can be anywhere from once a day, once a night, twice a day or even once every other week. If you there is a question that you have that isn’t answered yet, contact us and tell us what it is. In order to best perform their job, physical therapists need electronic medical record software that integrates well with other office and document management systems. The physical therapy electronic health records module is fully integrated into the IMS so that you no longer need to spend time creating data like patient details for every form or account usage. We offer implementation, training and follow-up support services by certified technicians. The Letter Writer greatly reduces the amount of time dedicated towards letter generation by making the process easier and faster.
No other software is specifically designed for pediatric needs with pre-populated templates, forms and other commonly used office documents.
You'll find that you'll be able to increase your cash flow by reducing errors and improving efficiency. It is one of those skills that we need to be concise and thorough with and it is also one of those skills that we are taught when we are training and often forget how to thoroughly and effective conduct an assessment of patients. It is an invaluable healthcare resource that you can keep with you on your iPhone, iPad, Kindle, e-book reader, android phone, mac, pc, laptop etc. Respiratory assessments are explored and reasons for the respiratory compromise are also discussed. We have put this resource together on the assessment of a patient that is fully referenced throughout with recent journal, government and medical book sources that are trusted in the specialty of healthcare. As with all the other resources that we have on offer on E Advanced Healthcare the formatting is better in the book itself, this is just for illustration purposes only.
As such they are free to be used for any purpose without conditions, unless such conditions are required by law. We constantly assess our patients and as such our assessments need to be thorough, systematic and accurate.
Obviously as working in critical care it is imperative that patient assessments are conducted both formally at the beginning of a shift and when significant changes are detected with the patient. This is done very formally when starting our career, however as time passes this skill becomes a lot more natural and fluent. This skill is generally learnt during our training, however when working in new areas there will be some new challenges that present themselves.


There are also moving safely assessment, which help us assess how to best mobilise the patients.
An initiative that is being used in Australia to improve communication is known as an acronym “ISBAR”. This book will provide some of that training which needs to be consolidated with practical “hands-on” clinical exposure. In the past the numbers of nurses related to the number of patients has been less than adequate.
For team members to gain respect and feel valued we need to be showing that we are able to provide thorough, accurate, appropriate and effective care – consistently.
For this to be done it is best that the patient’s body systems, or main organs are isolated and worked though in a progressive and logical order, as described shortly.
As I have mentioned it is best to perform a health assessment in a logical and progressive manner and I advocate performing a “top-to-toe” method. If we were not to give the painful stimuli then the patient may further decrease their level of consciousness and have a greater risk of other complications, miss treatment opportunities and have an increase risk of mortality.
The preferred method is central by either pressing firmly on the supraorbital region, rubbing the sternum or pinching the trapezius. This is why the preferred method of assessing the patient’s response to pain (if necessary) is by central stimulation. They can be asked if they feel any difference in hot and cold sensations, or getting objects which are out of sight, for example coins out of their pockets, or knowing which feet are on which pedal when driving.
As mentioned this can be obtained for free, but if you are not an Amazon prime member, then it will cost less than a cup of coffee. Technologies currently employed on many modern instrument platforms in clinical chemistry andhematology laboratories were restricted to the research environment just a few years ago. Because up to 60% of the testing process is centered around the preanalytical phase and preanalytical errors have been reported to account for more than two thirds of all laboratory errors,1,2 it is clear that improvements in this area will deliver the greatest incremental gains in the overall quality of clinical laboratory services. When we look at this in the context of the high pressure environment of the Emergency Department (ED), we see a paradox. Simply, this is a specimen which accurately reflects the in vivo situation of the patient at the time of collection. However, hemolysis, clotted specimens, ID error and poor quality specimens arising from IV line collections are commonly seen in this setting. Even a very low ID error rate can lead to serious medical errors involving significant adverse events for the patient and costly increased length of hospital stay.
In general, blood collection from peripheral lines is deemed to be acceptable only with newly placed lines ' before these are used for administration of fluids. 10 mL) sizes may be convenient but these can easily generate excessive negative pressure leading to high flow rates (and thus high 'shear' forces) which result in cell rupture. Additive carryover can also be prevented by ensuring the base of the tube is always below the top of the tube during the blood collection process. A recent study9 showed that the use of small gauge needles (25 G or smaller) is associated with increased variability in potassium levels compared to those in specimens collected using 23 G or 21 G needles ' leading the authors to conclude that 25 G needles cannot be recommended for collection of venous blood.
Whilst this method remains the one of choice from the perspectives of specimen quality and safety, blood collection using syringe collection methods (venipuncture or 'line draw') remain common in the ED setting. Pressure must not be applied to the syringe plunger to accelerate the rate of transfer as this is a certain recipe for hemolysis and may also lead to overfilling of the tube (a potential source of preanalytical error for many tests where the ratio of blood to additive is critical). Again, this specimen quality issue is often disproportionately represented by specimens originating from the ED. Inadequate mixing can lead to a reduced speed of coagulation in the specimen because of poor distribution of the clot activator throughout the specimen.
Mixing of these specimens is difficult due to the absence of an air bubble in the syringe (maintaining an anaerobic state with an absence of air bubbles is of course a critical requirement for a quality specimen).
This is important given the prevalence of electrolyte (and other) testing now performed on arterial blood gas specimens (and so-called 'venous' blood gas specimens obtained mainly for stat chemistry results including electrolytes). The other key issue with these specimens is contamination with skin flora resulting in falsely positive culture results.
Thorough skin preparation is essential in minimizing contamination of blood cultures with skin flora. Similarly, the ED environment can lead to increased safety risks to healthcare workers arising from exposure to these specimens. To say that education is required to ensure these issues are understood and addressed is to state the obvious. Again, education needs to be targeted at specific NSI issues in ED such as the need to use safety engineered sharps protection devices and the need to understand and follow best practices in high risk areas such as blood gas and blood culture collections (above).
Influence of the needle bore size used for collecting venous blood samples on routine clinical chemistry testing. CommunicationIt serves as a well-organized process of relaying necessary information from one care provider to another. It was then said that more people die from medical errors each year than from breast cancer or from motor vehicle accidents.
That is why it is now believed that errors are not made by defective people, but by defective systems.
It also includes the meat of the prescription, which contains the medication and strength, the amount to be taken, the route by which it is to be taken and the frequency. It generally does not matter if you write the generic or the brand name here, unless you specifically want to prescribe the brand name.
A NOTE: it is often suggested that to help reduce the number of medication errors, prescription writing should be 100% English, with no Latin abbreviations.
Our physical therapy software meets the requirements of physicial therapy practices and offers so much more. Instead, our IMS will allow you to pull information together to avoid redundant data entry. Integrating billing, scheduling, electronic medical records and other practice management features into one system greatly improves efficiency and accuracy. E Advanced Healthcare can help you with your patient assessment by providing you with a free resource that you can keep at the point of care on any electronic device.
You name the electronic resource and you can view it on there with the help of the Amazon Kindle free reading apps. A thorough cardiac assessment strategy is given including auscultation of the heart assessing the ECG and jugular venous pressure assessments. We have published these resources on Amazon, which means they are available to you from an outlet that you trust and that you can rely on.
Patient assessments are also performed non-formally during our continual contact with the patient. As such, we need to be able to react to the situations and respond appropriately, giving the attention to the most urgent need. In the medical speciality there are risk factors that are associated with their past medical history that may have an impact on upon their presenting complaint.
This has been supported by a multitude of sources, so Australia and other international areas have been working hard to establish the correct “ratio” for safe and effective patient care. This involves starting the assessment as the patient’s head and progressively moving down to their toes. Sternal pain, to be accurate, is not really central as the nerve pathways enter the spinal cord lower than is necessary to be classified as central in origin. This will help to assess the temperature sensation, fine touch sensation and position sensations. Please feel free and look at the other free resources that we have to offer on E Advanced Healthcare.
These advances have delivered significant gains in analytical performance in terms of precision, accuracy, sensitivity and specificity.
Whilst the ED is an area that has, arguably, the greatest need for accurate test results, workload pressures often lead to the collection of specimens of sub-optimal quality ' the heartland of preanalytical error. Rather, we have focused on problem areas most commonly encountered in a busy ED environment.
Because blood is a 'living fluid', collection of a quality specimen and delivery of this to the laboratory is far from easy.
When we consider some of the techniques and workplace situations that can lead to sub-optimal specimen quality, it is easy to understand how specimen collection performed 'in haste' can lead to these issues. A 'failure mode and effect analysis' study at the University of Kansas Hospital in 20033 showed that careful attention to all aspects of the specimen procurement process can lead to tangible improvements in the error rate.
Blood collection from peripherally inserted central catheters and other central lines is commonplace. Smaller size syringes (3 to 5 mL) are recommended along with a slow rate of draw on the plunger.
Similar examples can be found for other infusion fluids such as those used for total parenteral nutrition. This tube can precede all other tube types without concern of contamination (from carry-over of additive) leading to laboratory test result error. Examples of carryover include potassium from EDTA tubes contaminating tubes required for electrolyte analysis in the clinical chemistry laboratory or carryover of clot activators used in plain serum and serum gel tubes into sodium citrate tubes used for blood coagulation testing. Hemolysis is one of the most common causes of sub-optimal specimens leading to laboratory error6. Whilst a statistically significant difference between results obtained in specimens collected with 21 G and 23 G needles was not demonstrated, a bias was evident in free hemoglobin, potassium, calcium, chloride and sodium results obtained on specimens collected in the smaller, 23 G needles. First and foremost, healthcare professionals working in the ED should ensure that compliance with a correctly performed closed evacuated method for blood collection is maximized through education and training.
Whilst anticoagulants differ in terms of their solubility in blood, all specimen tubes with anticoagulant additives require thorough mixing. Whilst overt clotting is easily detected, micro-clots in whole blood EDTA specimens used for hematology testing may go undetected even though most modern analyzers have systems to detect clots and platelet clumps.
Depending on the time between specimen collection and centrifugation, the slow rate of coagulation may lead to the formation of fibrin particles and strands in the serum during or after centrifugation and before analysis. It makes no sense whatsoever to obtain a result a few minutes earlier if corners are cut that lead to a poor quality specimen and preanalytical error. Consistent procurement of quality specimens with the lowest possible rate of rejection by the laboratory will deliver the best quality results and significantly assist with average TAT by reducing the need to re-collect specimens. Some laboratories further decrease TAT by reducing centrifugation times and increasing relative centrifugal force (rcf). Because metal cations are susceptible to binding to regular, pharmaceutical grade heparin, use of this type of anticoagulant presents a source of preanalytical error (electrolyte results are reduced with excessive concentrations of heparin).
With regard to NSI, the use of a closed blood collection system using a winged butterfly set to draw directly into the blood culture vials is recommended.
The key to success is the use of a radial swabbing action (moving outwards from the intended puncture site).
The use of urine containers with leak-resistant caps is clearly an important preventative measure. An adjunct to this should be an underlying theme of improved efficiency (in terms of TAT, patient stay in ED) that adherence to best practices can deliver. Unless otherwise noted, BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company.
As if these figures were not staggering enough, a study was published recently in the Journal of Patient Safety that estimated the annual number of medical errors in U.S.
Because one day the attending doesn’t have time to go over every detail about patient care and this unsupervised intern prescribes the wrong medication leading to active error. Often times, the exact strength you want is not available, so the pharmacist will substitute an appropriate alternative for you.
A physician may prescribe 1 pack of an oral contraceptive with 11 refills, which would last the patient a full year. The gastrointestinal and renal systems are also examined in depth to give you the necessary tools to perform a thorough assessment of a patient. There are also APACHE scores, which aim to help us assess the severity of the patients’ illness.
This initiative has helped ensure that there are enough nurses available at certain times of the day to help ensure a safe and effective caring facility. If we learn a thorough and accurate method of performing a patient assessment and are able to communicate this effectively to members of the multidisciplinary team then we are more likely to be valued with regard to our impression and assessment.
Besides assessing the patient’s “systems” or organs, it is also important to thoroughly visualise their skin.
Peripheral painful stimuli is often applied by applying firm pressure on the top of the finger nails or by pinching the web between the thumb and index finger. Complementing these gains has been a steady improvement in quality control and quality assurance programs within clinical laboratories. As well, the pressured environment in the ED can lead to increased risk of needlestick injury (NSI) and exposure to potentially infectious specimens.
Many factors can combine to bring about significant change in the specimen from the point of collection through to the time of analysis.
Regardless of the regulations in this area, certain steps must be taken to ensure a quality specimen (as per the definition above) is obtained. The use of an evacuated collection technique is recommended as this provides all the benefits of a closed system collection. In addition to contamination leading to errors in results for glucose and electrolytes, the presence of infusion fluid in the specimen will of course introduce a dilution error which will affect all test results. Because some of the constituents of red blood cells (notably potassium and lactate dehydrogenase) are present in the cells at significantly higher concentrations than in serum or plasma, a small amount of hemolysis can lead to significant error if this is not detected. Use of large bore syringes in conjunction with small gauge needles adds to the mechanical trauma placed on the blood cells. The nature of the patient care process in ED, however, does mean that there will be a justifiable need, in some circumstances, to collect blood using a syringe based method. Inadequate mixing of EDTA specimens therefore remains as a potential source of platelet count (and other) errors and instrument sample probe occlusion. Data are now available to support this strategy using centrifugation times of less than four minutes (with rcf values of 3000 g) with certain plasma separation tubes11. Once filled to the correct level, the syringe must be 'rolled' between the palms of the hands for at least 5 seconds to ensure adequate mixing of the heparin anticoagulant. Whilst the modern balanced formulations allow higher concentrations of heparin to be used in blood gas syringes, recommended fill levels should be observed ' even the balanced formulations have their limits! When using this procedure, it is important to note that blood culture bottle(s) from the major manufacturers do not have a 'calibrated draw volume'. This process must not be rushed and the use of multiple swabs should be considered in situations where it is clear the site is heavily soiled. Containers with integral fittings to allow closed transfer of a calibrated volume of the specimen to evacuated urine collection tubes also assist with minimizing exposure and providing a sealed, high quality specimen.
Whatever the nature of any formal training, we strongly recommend that a member of the ED staff is nominated as an on-site educational resource with responsibility to provide on-going training and to monitor improvements.
And with the amount of material that needs to be covered in those 4 years, I’m sure writing prescriptions is not that well covered at any medical school.
For example, if you write prednisone (a corticosteroid) 50 mg, and the pharmacy only carries 10 mg tablets, the pharmacist will dispense the 10 mg tabs and adjust the amount the patient should take by a multiple of 5.


Pharmacists make these changes all the time, often without any input needed from the physician. This is convenient for both the patient and physician for any medications that will be used long term. When the patient complains of nausea, the nurse can give this medication because it has been prescribed.
With the correct number of nurses working on any particular shift it allows for more concise care and greater opportunities to be more thorough and as such provides the time necessary for a thorough assessment of a patient. Providing a concise and appropriate rationale for our assessment is also another important factor when communicating our findings to team members. This should follow the “top-to-toe” method of starting from the head and moving down to their toes. Concurrently, there has been an increase in the level of participation in external quality assurance programs. A trend towards automated systems that integrate barcoding of patient ID wristbands with a well defined and rigid specimen collection procedure will certainly help to reduce all errors of this type.
The two most common problems with 'line draw' specimens are hemolysis and contamination with infusion fluids.
Where this technique is employed, the use of an extension tubing set is recommended as a means of reducing the flow rate. Regardless of whether the specimen is acquired via syringe collection or direct evacuated collection, the line should first be flushed using sterile saline with a minimum of 2.5 times the 'dead space' of the catheter. Lysis of red cells due to exposure to liquid skin antiseptic agent is also common when insufficient time is allowed for the skin preparation agent to dry. Education and training is critical in these circumstances to ensure that healthcare professionals follow the correct procedures to minimise the potential for hemolysis. Inversion should be slow enough to allow the air bubble in the tube to completely traverse the length of the tube. At the very least, micro-clots and platelet clumps will adversely affect TAT for the ED because of the need to re-collect the specimen.
We have mentioned hemolysis and clotted specimens above but there are many other aspects of sub-optimal specimen quality that may go undetected in the laboratory. Laboratories must validate such data prior to adopting centrifugation conditions different to those recommended by the tube manufacturer.
Unlike evacuated blood collection tubes, blood culture bottle(s) will generally draw beyond their optimal fill level. Collection of specimens for blood culture through IV lines (of any type) is not recommended.
Where delays are anticipated between specimen collection and analysis, tubes with preservatives for chemistry urinalysis and micro culture and sensitivity testing are also available. Because physicians and nurses are the predominant stakeholders when it comes to preservation of the in vivo quality of a sample, education programs focusing on the causes and impact of sub-optimal sample quality are more likely to be effective in changing undesirable practices.
With this medical errors stands as the third leading cause of death after myocardial infarction and cancer. The strength looks different for one of these medications, even though all mean the same thing—5 mg.
Once completed with a signature and any other physician identifiers like NPI number or DEA number, the prescription is taken to the pharmacist who interprets what is written and prepares the medication for the patient. This way you don’t write a signed prescription without a patient name on it that accidentally falls out of your white coat and onto the floor in the cafeteria. Yes it is true that most of the current patient assessment books are going on sale for about $50 – $100, however you do not need to pay this!
For example looking at their head, face, ears, neck, etc., and then assessing their neurological function before moving down to their chest and respiratory assessments. In the developed world and in much of the developing world, all of this has combined to deliver high standards of analytical performance ' within the laboratory walls. Allied to this is the increasing use of computerized physician order entry which can deliver clear benefits in what may be described as the 'Pre- Preanalytical Phase'. As with the discussion on hemolysis below, this occurs as a result of mechanical trauma caused, mainly, by excessively high flow rates of blood from the catheter to the syringe or the evacuated tube.
Apart from errors arising from contamination of serum and plasma with intracellular contents of red cells, it should be noted that hemolysis can also lead to significant errors in coagulation testing. Apart from the choice of needle gauge (above), another key consideration is the way in which the specimen is transferred from the syringe to the blood collection tube.
In the clinical chemistry laboratory, undetected clots in heparin plasma specimens can also occlude sample aspiration probes. For this reason, a target fill level should be marked on the label of the bottle(s) (with reference to the fill level gradations).
Effective risk reduction strategies include establishing standardized protocols for pain management and protocols for reversal agents that can be administered without additional physician orders when warranted, as well as requiring an independent double check before administering intravenous HYDROmorphone doses.IntroductionHYDROmorphone (Dilaudid®) is a semisynthetic opioid agonist and a derivative of morphine. Again E Advanced Healthcare mission statement is to provide you with educational resources that are both useful, informative and accessible.
Whilst gross hemolysis is rarely missed, clinically meaningful variations of some laboratory tests have been observed in specimens where hemolysis is mild or almost undetectable.7,8 An example of this would be the production of a normal potassium result for a hypokalemic specimen. Levels of hemolysis less than 1% have been shown to impact significantly on test result accuracy for routine coagulation tests such as INR, and aPTT7. Devices are now available that facilitate 'closed transfer' from the syringe to the tube without the need to remove the tube cap. Perhaps more significant is the potential for very small clots (micro-fibrin) to be aspirated with the plasma sample and adversely affect test result accuracy (e.g. Note also that the bottle can be removed during the blood collection process to check the fill level on a flat surface if required.
Sometimes prescriptions are written this way and the decimal point can be missed, leading to a tenfold overdose (50 mg instead of 5 mg). It differs pharmacodynamically from its parent drug in potency, onset, duration, and the presence of an active metabolite, but the analgesic effect is the same.1 HYDROmorphone is used for moderate to severe pain.
Our e-book is going to cost less than a cup of coffee, so you have nothing to lose apart from some increased knowledge, improved patient care and enhanced professionalism.
2 mL draw in 13 mm x 75 mm, 5 mL capacity tube) have a reduced vacuum or more correctly, a higher internal pressure compared to 'full draw' tubes. For many laboratories, the ED contributes disproportionately to the tally of hemolyzed specimens. Adverse handling of the specimen leading to red cell rupture is also likely to damage platelets and facilitate increased activation of the latter. Whatever device is used, care must be taken to prevent NSI whether the specimen is to be analyzed at the 'point of care' or forwarded to a remote laboratory. Review and Quality AssuranceThe record can be utilized to assess the healthcare quality provided to the patient and the competency of the healthcare provider.7. Should you not want to get the e-book version or the paperback version of this great resource it is still one of the cheapest paperbacks available in the topic of medical assessments. It is worth noting that assay problems mediated by fibrin are not restricted to plasma specimens obtained from anticoagulated whole blood. Preparation of Patient’s CareThe chart can be the source of information for the whole healthcare team to plan the patient’s care.Good Features of Nursing Documentation and Recording1. For each entry, begin with a capital letter for the first letter of the initial word and end the statement with a period.2. For example, HYDROmorphone’s product label states that the initial IV dose for opioid-naive patients is 1 mg to 2 mg IV (slowly) every four to six hours as needed.7 However, there is literature that recommends against using 2 mg IV as a starting dose even in nonelderly patients.
Medication errors are preventable mistakes that can happen in labeling, packaging, prescribing, dispensing, and communications when the medication is ordered. Causes include: Incomplete patient information, with the health care professional not knowing about allergies and other medications the patient is using Miscommunication between physicians, pharmacists and other health care professionals.
For example, drug orders can be communicated incorrectly because of poor handwriting Name confusion from drug names that look or sound alike Confusing drug labeling Identical or similar packaging for different doses Drug abbreviations that can be misinterpreted As a part of its ongoing effort to fight these and other risks, CDER has entered into an agreement with ISMP to develop collaborative efforts to reduce preventable harm from medicines, and to more effectively reach consumers with information on how to use medicines safely.
AppropriatenessThe important and relevant information are the only ones noted in the chart.5. Comprehensiveness and Correct OrderCharting entries should be uninterrupted and are only allowed to continue on another line if the entry is done on another time.
ISMP shares these reports with MedWatch, FDA’s safety information and adverse event reporting system, which covers bad experiences with medical procedures and products that include drugs, devices, supplements and cosmetics. Despite this distinct difference in definition, ADR reports may be a source of potentially preventable events, even though the reporter thought the ADE could not have been prevented. This article presents an analysis of both medication errors and ADRs involving HYDROmorphone reported to the Pennsylvania Patient Safety Authority and discusses the predominant types of events involving HYDROmorphone.Medication Errors with HYDROmorphonePennsylvania healthcare facilities submitted 1,694 medication error reports to the Authority from January 2008 to October 2009 that described medication errors involving the use of HYDROmorphone.
For example, FDA was getting reports last year of dosing confusion involving a new, less concentrated form of acetaminophen for infants. ISMP contacted the agency about reports it had also received, and this information helped form a more complete picture of the number of events. FDA later issued a Drug Safety Communication advising consumers how to avoid confusion and dosing errors.
Predominant Medication Error Event Types  Associated with the Use of HYDROmorphone (n = 1,135, 67%),  January 2008 to October 2009 Wrong-Drug Errors with HYDROmorphoneIn 2007, a review of 8,400 wrong drug medication error reports submitted to the Authority showed that the most commonly involved drug pair was morphine and HYDROmorphone.15 Present analysis of wrong drug medication errors mentioning HYDROmorphone reveals that 70% involve mix-ups with morphine.
And the relationship will broaden FDA’s ability to reach out to these groups when there are issues with product safety and effectiveness. If there is a problem that arises from the way a medication is given to patients, , ISMP helps get the word out, Holquist says. Predominant Medications Associated with Wrong Drug Errors  involving HYDROmorphone (n = 146, 78.9%),  January 2008 to October 2009 Facilities did not enter enough detail into most of the event descriptions to determine all the reasons why these events took place. In situations like that, ISMP is able to reach specific audiences through their newsletters.
Aside from the information stated in the Kardex, other important data regarding the patient’s care is also endorsed to the receiving team.Telephone ReportsTelephone reports are usually brief and clear.
The nurse found 24 vials of medication in the drawer: 20 were Dilaudid, but 4 were morphine sulfate. For example, typing in the name of a medication will bring up information about side-effects, duplicative treatments and drug interactions. The RN [registered nurse] had previously given patient a “prn” dose of Dilaudid but is not sure if the dose was Dilaudid or morphine.The pharmacist dispensed morphine PCA [patient-controlled analgesia] (as seen on manufacturer’s labeling) with a pharmacy label for HYDROmorphone PCA. A free safety alert service, about medications patients or their family members are taking, also is available. The nurse receiving the PCA did not catch it, but another nurse, who was about to hang it on the patient, did catch it. SHARE Facebook Twitter tweetCharity Marquez RNBeing a nurse-writer reflects both my profession and passion for my calling. I believe writing is the greatest way for me to promulgate the insights that I'm best with. Medical-Surgical Nursing and Anatomy & Physiology are my two strongest specializations in the field. Analysis of the descriptions of events that occurred during the administration node shows that most of the reported cases did not give enough detail to determine specifically what went wrong but simply stated that the patient received a higher dose than what was intended (57.4%, n = 112).
For example, some reports indicated orders were written without designating that HYDROmorphone should be given “as needed,” which could have led to the administration of this medication more frequently than was needed.The prescriber wrote for every five-minute dosing of hydromorphone tablets (2 mg) prn. An order was written for a postoperative patient to receive 1 mg Dilaudid PCA every 15 minutes with a 16 mg 4-hour dose limit. The original prescriber insisted on the dose, and the nurse then brought the order to the attention of the director of anesthesia, who did not change the order. That physician asked what is usually given and the nurse replied “2 mg,” so the order was clarified as “2 mg.” The nurse administered the 2 mg, which led to severe respiratory depression. Analysts searched for “HYDROmorphone” or “Dilaudid” in the suspected medication, other medication, and the event description fields to find ADR reports that may have involved HYDROmorphone alone or in combination with other medications.There were 937 ADR reports submitted to the Authority between June 2004 and October 2009.
Almost 90% (n = 842) of the ADR reports discussed events that were considered to have not harmed patients. The three most common broad categories of reactions described in the narratives include allergic reactions, respiratory depression, and central nervous system effects (see Table 3). For this analysis, an inappropriate dose was considered to be a dose that was one of the following: Greater than a 1 mg dose for the general adult population for an opioid-naive patient1 mg or greater for an elderly patient who was opioid-naiveA frequency of administration that allowed for the administration of HYDROmorphone too frequently for that patient populationAnalyses of these events reveal problems with the prescribing of inappropriate doses and multiple medications that have sedative properties. Within an eight-hour period, the patient received morphine 2 mg IV, Dilaudid 2 mg IV two times, and was started on a Duragesic® (fentanyl) patch.
Narcan® was given, and the patient responded immediately; pulse oximetry was monitored and was 100%. The Dilaudid prn order was discontinued, the Duragesic patch remained on, and the patient had no further episodes of unresponsiveness.An adult patient was admitted with a right ureter stone.
Two hours later, the patient was speaking with staff, but within a half hour, the patient was found unresponsive with shallow breathing and a faint heart rate of 40. Four hours later, on the postoperative surgical unit, the patient required Narcan 1 mg for decreased respirations and oversomnolence.An elderly patient, admitted with back pain, received morphine 4 mg and a total of 2 mg of Dilaudid within a six-hour period in the ED. When the patient arrived to the nursing unit, the patient’s heart rate was 120 and oxygen saturation was 80% on room air. Risk reduction strategies such as constraints and standardization, which focus on system improvement, will be more effective than education alone, which relies on individual performance.
Is that correct?” when nurses retrieve HYDROmorphone.21RedundanciesRequire an independent double check before administering IV HYDROmorphone doses. Since nurses routinely obtain narcotics from floor stock, the typical pharmacist-nurse double check is not in place (as it is with specific patient doses dispensed from the pharmacy). Some ADCs can be programmed to require a witness when selected narcotics are removed or when the override feature is used to access selected narcotics. Reminders can also appear on the screen.21Patient MonitoringEstablish guidelines for appropriate monitoring of patients who are receiving opioids, including frequent assessment of the quality of respirations (not just a respiratory rate) and specific signs of oversedation.
Educate staff about the differences between HYDROmorphone and morphine, as some of the reported mix-ups have been due to the mistaken belief that HYDROmorphone is the generic name for morphine.21Monitoring of ADRsAs demonstrated by the analysis of ADR reports submitted to the Authority, these reports serve as a potentially rich source of information to identify risk with the use of HYDROmorphone, as well as other opioids in the facility. Consider reviewing ADR reports, as well as the use of “trigger” drugs used to reverse the effects of opioids, like naloxone, to get a broader picture of the harm resulting from the misuse of HYDROmorphone.Consider measures other than practitioner reporting of medication errors to evaluate your organization’s safe use of HYDROmorphone, including assessing core processes associated with HYDROmorphone use by using process measures. Visit the Authority’s Web site to view or download a sample tool that can be used to identify and monitor actual or potential problems with the use of HYDROmorphone.NotesHill HF, Coda B, Tanaka A, et al.
Multiple-dose evaluation of intravenous hydromorphone pharmacokinetics in normal human subjects. Safety and efficacy of hydromorphone as an analgesic alternative to morphine in acute pain: a randomized clinical trial. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone).
You may use the following examples or come up with your own.A physician wrote an order for a 67-year-old opioid-naive patient for HYDROmorphone 4 mg intravenous (IV) administration as needed for pain. The patient received one dose and was later found with a low oxygen saturation, low respiratory rate, and decreased responsiveness. Standardize protocols and concentrations for HYDROmorphone.Implement redundancies and double checks in the administration process of HYDROmorphone.



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