Preferred Terms and Icons for Labels on Electrosurgical Units: Survey of VA Nurses

Taylor, Miles; Li, Airan; Estock, Jamie L.; Boudreaux-Kelly, Monique Y.; Pham, Ivan Thibault; Casey, Maureen

doi:10.2345/0899-8205-53.2.102

Cited by 2 publications

(3 citation statements)

References 23 publications

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“…In contrast, when personnel use multiple models of a medical device, then the variability in design across models may increase the likelihood for misinterpretation of a device interface and induce a use error. [33][34][35] As a result, facilities should consider using a uniform inventory of infusion pumps, which may reduce the likelihood of erroneous pump programming.…”

Section: Safety Strategiesmentioning

confidence: 99%

Risk of Medication Errors With Infusion Pumps

Taylor¹,

Jones²

2019

PatientSaf

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The risk of medication errors with infusion pumps is well established, yet a better understanding is needed of the scenarios and factors associated with the errors. Our study explored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018. Our study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, we did find that 22% of events involved a high-alert medication. Our study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, we manually reviewed a free-text narrative field in each event report to better understand the nature of errors. For example, we found that a majority of wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.

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Section: Safety Strategiesmentioning

confidence: 99%

Risk of Medication Errors With Infusion Pumps

Taylor¹,

Jones²

2019

PatientSaf

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“…For warning and instructional signage to be effective, it must be carefully designed to increase reader interpretation and compliance with instructions. There is a robust body of evidence that informs the design of warning signs [26][27][28][29][30][31][32][35][36][37][38][39][40] and we believe this evidence can be generalized to signs that guide visitor behavior. We identified several design characteristics that can be used to increase sign effectiveness.…”

Section: Design Recommendations For Effective Signagementioning

confidence: 99%

“…Graphics are helpful for individuals with low literacy or a language barrier and can increase efficiency of interpretation. 26,40…”

Section: Symbols or Pictorialsmentioning

confidence: 99%

Visitor Behaviors Can Influence the Risk of Patient Harm: An Analysis of Patient Safety Reports From 92 Hospitals

Sanchez¹,

Taylor²,

Jones³

2022

PatientSaf

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Background: Previous research has shown that visitors can decrease the risk of patient harm; however, the potential to increase the risk of patient harm has been understudied. Methods: We queried the Pennsylvania Patient Safety Reporting System database to identify event reports that described visitor behaviors contributing to either a decreased or increased risk of patient harm. Event reports from January 1 to June 30, 2019, were searched for keywords and reviewed for inclusion criteria. Event reports were manually coded to identify visitor influence on risk of patient harm (e.g., increase or decrease), visitor behavior, and event type. Results: A total of 427 event reports were analyzed and we identified five categories of visitor behavior that influenced patient safety by either decreasing or increasing the risk of patient harm. We found that 63.7% (272 of 427) of event reports described a visitor behavior that decreased the risk of patient harm and the remaining 36.3% (155 of 427) of reports described behavior that increased the risk of harm. There was a greater variety of visitor behaviors that contributed to an increased risk of patient harm, as opposed to a decreased risk of harm. The visitor behavior most frequently associated with a decreased risk of patient harm was communicating with staff (91.2%, 248 of 272); for example, to inform staff of deterioration of a patient’s condition. The visitor behavior most frequently associated with an increased risk of patient harm was moving a patient (63.2%, 98 of 155). Across the 427 event reports, we found that visitor behavior was associated with seven event types; the falls event type (61.6%, 263 of 427) and medication-related event type (14.8%, 63 of 427) occurred most frequently. Conclusion: The current study provides insight into which visitor behaviors are contributing to a decreased risk of patient harm and adds to the literature by identifying behaviors that can increase the risk of patient harm, across multiple event types. Table 6 and Table 7 outline potential safety strategies that staff and facilities may consider using to target visitor behavior. As outlined in Table 6, the use of warning and instructional signage can be a relatively low-effort and effective strategy to influence visitor behavior and address multiple behavior categories and event types.

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Preferred Terms and Icons for Labels on Electrosurgical Units: Survey of VA Nurses

Cited by 2 publications

References 23 publications

Risk of Medication Errors With Infusion Pumps

Risk of Medication Errors With Infusion Pumps

Visitor Behaviors Can Influence the Risk of Patient Harm: An Analysis of Patient Safety Reports From 92 Hospitals

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