Errors in the Operating Room: Difference between revisions
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[https://twitter.com/cap_mcawesome/status/1367828188114587650?s=21 Tweetorial: Learning from Errors in the OR] | |||
[https://pubmed.ncbi.nlm.nih.gov/35649513/ Preventing Medication Errors in Pediatric Anesthesia: A Systematic Scoping Review] | |||
[https://onlinelibrary.wiley.com/doi/10.1111/pan.14535 Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia] | |||
[https://onlinelibrary.wiley.com/doi/10.1111/pan.14524 The German guidelines for medication safety in pediatric emergencies] | |||
[https://pubmed.ncbi.nlm.nih.gov/36239463/ Medication safety in pediatric anesthesia: An educational review and a call to action] | |||
[https://pubmed.ncbi.nlm.nih.gov/36239463/ Medication safety in pediatric anesthesia: An educational review and a call to action] | |||
[https://pubmed.ncbi.nlm.nih.gov/28370645/ Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia] | |||
[https://pubmed.ncbi.nlm.nih.gov/26501385/ Evaluation of Perioperative Medication Errors and Adverse Drug Events] | |||
[https://www.apsf.org/wp-content/uploads/newsletters/2010/spring/pdf/APSF201006.pdf APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice] | |||
[https://pubmed.ncbi.nlm.nih.gov/28742772/ Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative] | |||
[https://journals.lww.com/pqs/Fulltext/2022/09000/Independent_Double_check_of_Infusion_Pump.6.aspx Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm] | |||
[https://pubmed.ncbi.nlm.nih.gov/28079581/ Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study] | |||
[https://pubmed.ncbi.nlm.nih.gov/35521011/ Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability] | |||
[https://pubmed.ncbi.nlm.nih.gov/25077248/ Institute of Medicine (US) Committee on Quality of Health Care in America: To Err is Human: Building a Safer Health System] | |||
[https://www.hastam.co.uk/an-encounter-with-an-error-trap/ Highly S. An Encounter with an Error Trap] | |||
[https://pubmed.ncbi.nlm.nih.gov/22157846/ Cognitive errors detected in anaesthesiology: a literature review and pilot study] | |||
[https://pubmed.ncbi.nlm.nih.gov/36178188/ Educational Review: Error traps in anesthesia for pediatric liver transplantation] | |||
[https://www.bjanaesthesia.org/article/S0007-0912(23)00251-9/fulltext Clinical impact of task interruptions on the anaesthetic team and patient safety in the operating theatre] | |||
[https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16095 Handling injectable medications in anaesthesia - Guidelines from the Association of Anaesthetists] | |||
Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-patient blood transfusion error: leveraging Technology to overcome human error in intraoperative blood component administration. Jt Comm J Qual Patient Saf. 2019 Mar; 45(3): 190-198. PMID: 30389466 | |||
The Joint Commission. Sentinel Events (SE). Comprehensive Accreditation Manual for Hospitals. Updated July 2021. | |||
Posner KL, Kent CD, Mincer SL, Domino KB. Anesthetic risk, quality improvement, and liability. In: Barash PG, Cullen BF, Stoelting RK, et al., eds. Clinical Anesthesia. 8th ed. Philadelphia, PA: Wolters Kluwer; 2017: 101. | |||
[https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16166 The impact of using prefilled syringes on a standard operating procedure for preparing injectable medicines in clinical areas] | |||
[https://resources.wfsahq.org/atotw/distractions-in-the-or/ WFSA Tutorial: Distractions in the OR] | |||
[https://wfsahq.org/news/latest-news/introduction-to-the-morbidity-mortality-tool-kit-for-lmics/ WFSA: Introduction to the Morbidity & Mortality Tool Kit for LMICs] | |||
[https://pubs.asahq.org/anesthesiology/article/140/3/387/139424/A-Quality-Improvement-Initiative-to-Reduce-Adverse A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study] | |||
[https://pubmed.ncbi.nlm.nih.gov/38251720/ The vial can help: Standardizing vial design to reduce the risk of medication errors] | |||
[https://www.ismp.org/ Institute for Safe Medication Practices] | |||
Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology 2016;124(1):25-34. (In eng). DOI: 10.1097/aln.0000000000000904. | |||
Kahneman D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol 2003;58(9):697-720. (In eng). DOI: 10.1037/0003-066x.58.9.697. | |||
Jelacic S, Bowdle A, Nair BG, Kusulos D, Bower L, 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):410-21. (In eng). DOI: 10.1213/ane.0000000000000256. | |||
Thomas JJ, Bashqoy F, Brinton JT, Guffey P, Yaster M. Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability. Hospital pharmacy 2022;57(1):11-16. (In eng). DOI: 10.1177/0018578720970464 | |||
[https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/application-of-seips-and-accimap-to-a-patient-safety-incident-r11143/ Application of SEIPS and AcciMap to a patient safety incident] | |||
Bitan Y, O’Connor MF, Nunnally ME. The vial can help: Standardizing vial design to reduce the risk of medication errors. Int Anesthesiol Clin. 2024 Apr 1;62(2):58-61. Doi: 10.1097/AIA.0000000000000431. Epub 2024 Jan 22. PMID: 38251720. | |||
Martin LD, Grigg ED, Verma S, Latham G, Rampersad SE, Martin LD: Decreased Medication Errors in Pediatric Anesthesia Practice: Outcomes from a Failure Mode and Effects Analysis. Pediatr Anesth 2017; 27: 571-80. (PMID: 28370645) | |||
Grigg E, Martin LD, Ross FJ, Roesler A, Rampersad SE, Haberkern CM, Low DKW, Carlin K, Martin LD: Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study. Anesth Analg 2017; 124:1617-25. (PMID: 280079581) | |||
[https://youtu.be/GEDMYsm3Nxs?si=iMH04qNn2g7a3vsj YouTube: Dennis Quaid talks about his twins and medical negligence] | |||
[https://pubs.asahq.org/anesthesiology/article/139/4/492/138452/Intracranial-Nasogastric-Tube-Placement-in-a Intracranial Nasogastric Tube Placement in a Nontrauma Patient] | |||
[https://www.bjanaesthesia.org/article/S0007-0912(24)00266-6/fulltext Relationship between mental effort and workload during routine anaesthesia] | |||
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16381 | |||
Latest revision as of 01:37, 27 July 2024
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Relevant Article Depot:
Tweetorial: Learning from Errors in the OR
Preventing Medication Errors in Pediatric Anesthesia: A Systematic Scoping Review
Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia
The German guidelines for medication safety in pediatric emergencies
Medication safety in pediatric anesthesia: An educational review and a call to action
Medication safety in pediatric anesthesia: An educational review and a call to action
Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia
Evaluation of Perioperative Medication Errors and Adverse Drug Events
Highly S. An Encounter with an Error Trap
Cognitive errors detected in anaesthesiology: a literature review and pilot study
Educational Review: Error traps in anesthesia for pediatric liver transplantation
Handling injectable medications in anaesthesia - Guidelines from the Association of Anaesthetists
Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-patient blood transfusion error: leveraging Technology to overcome human error in intraoperative blood component administration. Jt Comm J Qual Patient Saf. 2019 Mar; 45(3): 190-198. PMID: 30389466
The Joint Commission. Sentinel Events (SE). Comprehensive Accreditation Manual for Hospitals. Updated July 2021.
Posner KL, Kent CD, Mincer SL, Domino KB. Anesthetic risk, quality improvement, and liability. In: Barash PG, Cullen BF, Stoelting RK, et al., eds. Clinical Anesthesia. 8th ed. Philadelphia, PA: Wolters Kluwer; 2017: 101.
WFSA Tutorial: Distractions in the OR
WFSA: Introduction to the Morbidity & Mortality Tool Kit for LMICs
The vial can help: Standardizing vial design to reduce the risk of medication errors
Institute for Safe Medication Practices
Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology 2016;124(1):25-34. (In eng). DOI: 10.1097/aln.0000000000000904.
Kahneman D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol 2003;58(9):697-720. (In eng). DOI: 10.1037/0003-066x.58.9.697.
Jelacic S, Bowdle A, Nair BG, Kusulos D, Bower L, 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):410-21. (In eng). DOI: 10.1213/ane.0000000000000256.
Thomas JJ, Bashqoy F, Brinton JT, Guffey P, Yaster M. Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability. Hospital pharmacy 2022;57(1):11-16. (In eng). DOI: 10.1177/0018578720970464
Application of SEIPS and AcciMap to a patient safety incident
Bitan Y, O’Connor MF, Nunnally ME. The vial can help: Standardizing vial design to reduce the risk of medication errors. Int Anesthesiol Clin. 2024 Apr 1;62(2):58-61. Doi: 10.1097/AIA.0000000000000431. Epub 2024 Jan 22. PMID: 38251720.
Martin LD, Grigg ED, Verma S, Latham G, Rampersad SE, Martin LD: Decreased Medication Errors in Pediatric Anesthesia Practice: Outcomes from a Failure Mode and Effects Analysis. Pediatr Anesth 2017; 27: 571-80. (PMID: 28370645)
Grigg E, Martin LD, Ross FJ, Roesler A, Rampersad SE, Haberkern CM, Low DKW, Carlin K, Martin LD: Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study. Anesth Analg 2017; 124:1617-25. (PMID: 280079581)
YouTube: Dennis Quaid talks about his twins and medical negligence
Intracranial Nasogastric Tube Placement in a Nontrauma Patient
Relationship between mental effort and workload during routine anaesthesia
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16381