Promoting Medication Safety: Free ISMP Nurse Advise-ERR Newsletter

happy&healthy · Mar 6, 2005

Thank you for making people aware of this Continuing-ed. resource:

http://www.ismp.org/NursingArticles/list.htm.

NurseFirst · Mar 11, 2005

check out the
institute for safe medication practices (ismp) nurse advise-err
a medication safety newsletter written especially for nurses by nurses. as an adjunct publication to the widely read ismp medication safety alert! acute care edition, this monthly, two-page newsletter will be offered free to nurses during 2003 and 2004 through an unrestricted grant from eli lilly and company used to fund the start-up of this important publication. while the drug safety issues covered in the ismp medication safety alert! acute care edition are certainly applicable to nurses, anecdotal evidence suggests that crucial medication safety information may not be reaching very busy front-line nurses who are continuously overwhelmed with information related to a wide variety of important issues. through its unique design, it's anticipated that ismp nurse advise-err will be just the vehicle needed to deliver valuable medication safety information to nurses who administer medications.
in the february 2004 issue of nurse advise-errä, a peer-reviewed newsletter published by the institute for safe medication practices.

-- could you mix up iv lines while setting up or programming a multiple-channel iv pump?
-- the risks of leaving an unneeded intra-arterial line in place.
-- ismp issues a list of high-alert medications.
-- helpful questions to use when evaluating infusion pumps.
-- enter the ismp patient safety contest, being held in celebration of national patient safety week, march 7-13, 2004.

free ce: you can earn free continuing education units for reading the 2003 issues of this newsletter. visit www.ismp.org/nursingce to participate.

nurse advise-errä is offered free during 2004 through an educational grant from eli lilly and company. we encourage you to redistribute it to as many nurses as possible in your healthcare system. if you're not already a subscriber, visit http://www.ismp.org/nursingarticles/index.htm to sign up. back issues of the newsletter are available at: http://www.ismp.org/nursingarticles/list.htm.
i receive this publication at work and distribute throught my organization. recommend that all nurses & nursing students read it. karen

i also discovered a couple of other organizations that are working to reduce medical mistakes: http://www.leapfroggroup.org which is 160 organizations which are group health care consumers--that is, they buy group health insurance. they have hospital reviews which indicate where, in using the various leapfrog levels (there are 4) they have implemented. (for instance, the first is cpoe--computerized physician order entry--for physicians to input prescriptions.)

there is also another, which i discovered from the leapfrog site,

http://www.qualityforum.org

haven't spent that much looking at that, yet.

nursefirst

Home Health Columnist / Guide · Sep 7, 2005

from september 2005 issue of nurse advise-err, a peer-reviewed newsletter published by the institute for safe medication practices (ismp).

in this month's issue:

here's what you'll find in the september 2005 issue ...

--cultural diversity and medication safety

--all is not as it seems: protonix or protamine?

--educational materials resource for your asian-language speaking patients

--enteral feeding drug-nutrient interactions

special announcements:

teleconference. our teleconference, "risk reduction strategies for medication errors in the perioperative setting," will be held on wednesday september 21st at 1:30 pm edt. speakers from ismp, the association of perioperative registered nurses (aorn), and ismp-canada will focus on medication and patient safety in the perioperative setting and will help organizations meet the 2006 jcaho patient safety goal requiring the labeling of all medications and medication containers on and off the sterile field in perioperative and other procedural settings. information provided by the expert speakers will lay the foundation for how to achieve a genuine culture of safety in the perioperative setting. all speakers will present practical strategies that can be proactively used by individual practitioners and clinical departments. more information and registration at: http://www.ismp.org/t/200509/index.htm.

new ismp tool online! please visit our website www.ismp.org for access to our newest tool, ismp’s list of confused drug names. please note that we also have updated and reformatted two of our existing tools: ismp’s list of high-alert medications, and ismp’s list of error-prone abbreviations, symbols, and dose designations.

nurse advise-err is offered free to nurses through an educational grant from mckesson. we encourage you to designate a primary subscriber in your organization who then redistributes it to as many nurses as possible in your healthcare system.

back issues of the newsletter are available at: http://www.ismp.org/nursingarticles/list.htm.

Home Health Columnist / Guide · Dec 18, 2006

[color=#0a3f82]ismp nurse [color=#0a3f82]advise-[color=#960122]err

medication [color=#4d4d4d]safety alert!

educating the healthcare community about safe medication practices

[color=#4d4d4d][color=#ffffff]december 2006 volume 4 issue 12

[color=#4d4d4d][color=#ffffff]highlights:

[color=#4d4d4d]preventing errors with neuromuscular blocking agents
easy catch, good rule – verify dosage orders.
lithium in mg or meq?
does the nose know? the nostril(s) makes a difference.

[color=#4d4d4d]

http://www.ismp.org/newsletters/nursing/issues/nurseadviseerr200612.pdf

VickyRN, MSN, DNP, RN · Dec 27, 2006

toward safer iv medication administration: the narrow safety margins of many iv medications make this route particularly dangerous

nursingcenter - library - journal issue - article

high-alert drugs: strategies for safe i.v. infusions

to prevent medication errors with the most dangerous drugs, use these evidence-based strategies. about 80% of all patient deaths are caused by some 20 drugs. do you know what these high-risk medications are and has your facility taken the necessary steps to safeguard against errors?

medication safety: look-alike/sound-alike drugs in home care

nursingcenter - library - journal issue - article

pump away high-risk infusion errors

nursingcenter - library - journal issue - article

teaching correct use of inhaled medications

nursingcenter - library - journal issue - article

VickyRN, MSN, DNP, RN · Dec 27, 2006

guidelines for preventing medication errors in pediatrics - great resource!

VickyRN, MSN, DNP, RN · Dec 27, 2006

preventing adverse drug events

simply put, an adverse drug event (ade) is an injury or other undesirable response to a drug administered for a therapeutic effect. this includes not only adverse drug reactions but also adverse outcomes associated with omissions in therapy, such as the failure to administer a drug as ordered. medication errors are a common cause of ades, but allergic or immunologic responses and other adverse reactions, including toxicity and drug interactions, are also considered ades, even when not related to an error.

although some ades are little more than minor annoyances, others are life-threatening. the cost of ades in patient suffering and added health care expense is enormous. according to one estimate, ades increase the cost of hospitalization by $2,200 to $3,200 per stay and prolong hospital stays by 2 days on average.

as part of its 100,000 lives initiative, the institute for healthcare improvement is campaigning to prevent ades and save lives through medication reconciliation. for details on this initiative, see “best-practice interventions: how medication reconciliation saves lives” on page 63. in this article, i'll discuss why various types of ades occur and how you can help promote a culture of medication safety in your facility.

VickyRN, MSN, DNP, RN · Dec 29, 2006

awesome video and resource:

preventing medication errors

Home Health Columnist / Guide · Jan 2, 2007

recommendations for the safe use of handling of cytotoxic drugs ...

VickyRN, MSN, DNP, RN · Jul 24, 2007

how-to guide: prevent adverse drug events (medication reconciliation)

medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital. if any pre-admission medication is either not ordered or not explicitly declared to be inappropriate, the nurse or pharmacist should contact the patient’s physician. the physician should then either order the medication or formally confirm that the omission was deliberate.

how-to guide: prevent harm from high-alert medications

high-alert (or high-hazard) medications are medications that are most likely to cause significant harm to the patient, even when used as intended. the institute for safe medication practices (ismp) reports that, although mistakes may not be more common in the use of these medications, when errors occur the impact on the patient can be significant.

the joint commission on accreditation of healthcare organizations (jcaho), referring to ismp’s work, describes high-alert medications as those “that have the highest risk of causing injury when misused” (“high-alert medications and patient safety.” joint commission sentinel event alert. november 19, 1999).

based on reports submitted to ismp, a review of literature, and the experience of many hospitals around the country, the list of high-alert medications includes as many as 19 categories and 14 specific medications. although it is important to improve management of all of these medications, some of them are used more frequently and the resulting harm from this subset may be more significant.

the 5 million lives campaign

a national initiative led by ihi, the 5 million lives campaign aims to dramatically improve the quality of american health care by protecting patients from five million incidents of medical harm between december 2006 and december 2008. the how-to guides associated with this campaign are designed to share best practice knowledge on areas of focus for participating organizations. for more information and materials, go to www.ihi.org/ihi/programs/campaign.

Home Health Columnist / Guide · Apr 11, 2008

institute for safe medication practices nurse survey

problems in nursing practice that contribute to errors

please visit www.fc4research.com/me2008/ to complete a brief questionnaire to help ismp identify problems in nursing practice that contribute to errors.

the deadline for survey responses is june 30, 2008

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to report medication errors, call ismp at 1-800-fail-saf(e) or complete the form at this ismp link: https://www.ismp.org/orderforms/reporterrortoismp.asp. all communications are kept confidential.