Institute For Safe Medication Practices

Readership Survey for Nurse Advise-ERRT

Total: 1324

1. The newsletter increases my understanding of the causes and prevention of errors.

16%

77%

2. The recommendations for error prevention are practical and helpful.

21%

72%

3. The information is relevant to my practice.

10%

20%

66%

4. The content stimulates discussion among my colleagues.

21%

26%

46%

5. The newsletter helps me use technology more safely in my everyday practice.

17%

25%

52%

6. I have used information from this newsletter to:

a. Make changes in my workplace

16%

17%

Yes

64%

If yes, please provide examples:

Sharp injury prevention; PCA usage

I am the hospital Risk Manager and use examples from this newsletter when providing education to both nurses and physicians.

Separate look alike/ sound alike meds from floor stock

Use alerts and suggestions as safety tips to distribute to all nurses in our organization.

Improve medication administration safety & competencies

Powerpoint presentations for staff development - communicate actual & potential errors

Helps to increase awareness of staff to have pertinent examples to share with nurses at staff meetings, case conferences.

Ensuring safety with verbal orders

Examples of errors to create learning opportunity

Sound alike drug. Labelling IV lines with medication names

e.g. PCA pump: proactive response system wide to reduce any potential errors, with emphasis on points noted by the article printed.

I made copies of "check it out" discussing methemglobinemia, laminated them and keep them with my methylene blue. Also I share the examples with my staff for learning.

The newsletter is distributed to ALL nursing units, nurse managers and the medication team. Articles are discussed at the meetings and policies and practices are re-evaluated to ensure the safest medication administration delivery possible.

As an Advanced Practice Nurse, I participate in many multidisciplinary committees and write many policies and procedures (both unit-based and system-wide). ISMP recommendations have been shared at many of these meetings and have been incorporated into most, if not all, medication-related policies.

intimidation

Reivsed policies and procedures and included the newsletter as a reference.

As the educator fro critical care, I post each new newsletter,stimlualtes discussion at meetings,has helped develop new protocols

USE PRATICAL TIPS TO USE IN NEWSLETTER TO STIMULATE DISCUSSION WITH STAFF

double check practices for IV and other medications.

Used the issue on Insulin to update a table of insulins used here, Discuss each issue at our Clinical Excellence Committee and highlight med errors with relevance to our hospital.

Shared newsletter with our medication committee co-chair who has circulated many of the safe practices and alerts to staff

We pass the newsletter among all of us. We have incorporated more independent checks and double check many more meds--we actually have a high alert med list now where we didn't before.We also always double check pediatric meds.

Helps make us more aware of the many ways errors can so easily occur and that it is not just isolated to one hospital or clinic.

awareness of common type of errors to be on the look out for, need to be firm with physicians who continue bad practices

I am Patient Safety Mgr. and think it is terrific! It always contains pertinent information. We make sure that it is available to the whole nursing staff.

this newsletter is reviewed at every monthly meeting of our mutidisciplinary barcode medication administration committe and I post it on our universal drive for access to all.

Used information to implement and enforce National Patient Safety Goals

We have re-printed (with permission) info and disseminated it widely throughout the state of KY.

We have re-initiated the double check for insulin administration and also added heparin.

I'm the Nursing PI Coordinator, so info is shared with all Head Nurses and appropriate PI teams.

Added to part of the educational system for nurses to supplement the National Patient Safety goals

I am the education specialist for a Surgical Service Line. Monthly I post the newsletter in the nurses station to keep them informed of good practice and potential errors.

handwriting, look alike sound alike

Improved safety awareness of nursing staff

orientation of new staff especially new graduates.

Policy changes about medications. Not abbreviating medication names.

start safety walk arounds in my facility

to emphasize the importance of writing legibily

Point out packaging changes in sterile water and 5% glucose water provided by a formula manufacturer that increased the chances of an error. Encouraged our manager to provide markers to label things at the bedside.

I have changed labelling procedures on student medication. Similar names/medications are highlighted.

More cautious with drugs-look alike/sound alike; storage; triple checks

As a nurse educator I post the newsletters for my students in the classroom and I discuss areas that pertain to preventing errors in the clinical areas.

We implemented new and more stringent "double-check" systems for medication administration as well as pre-procedurally (sp?).

As Quality Manager I am involved in Medication error reporting and it has been helpful in this area.

Provides a resource for policy and decision making

Information included in inservices and educational programs for nursing, as well as the pharmacy staff.

I work in a non-traditional environment where nurses do not necessarily have daily access to the more standard, clinical approach to medication situations. The newsletter provides that type of connection for us. Because we are a non-traditional nursing setting, it is the concept/rationale which drives a particular strategy, which is most helpful in application.

Changed the way the review of medication errors has been done.

Education on improper connection of IV tubing to O2 and other inappropriate devices.

Changes PCA Pump procedure to incorporate recommendation for PCA by proxy

Provides supporting examples to ongoing medication/patient safety efforts; Distribute to Nursing Quality Council staff reps

Making sure containers are properly labeled. Providing "ticklers" for look alike and sound alike meds

Some of the articles have been used to stimulate discussions in the classroom.

Discussion at P&T. Presented & discussed at staff meetings. USed in discussion when an event / error occurs, process reviews, etc.

Have used information provided as part of risk reduction strategies at unit and organizational level

I am a manager and have used you info in staff meetings multiple times.

Helped in policy revisions with PCAs.

After I reviewed the information on orange color coded insulin syringes and the risk of other syringes having the same color coding was addressed by contacting our purchasing department to assure that current stock did not place us at risk and to implement processes that would prevent other orange color coded syringes from arriving at our institution.

we have used information to revise policy and procedures to meet JCAHO standards

Labeling PCA - ptuse only, adding education to PCA template WE now use "tall letter" to distinguish Glyburide and Glybizide

Gave info to my preceptors and they shared with staff.Nurse managers reviewed and ensured all staff obtained info

INformation was used in the purchase of new PCA and epidural pumps. Information has been incorporated into narcotic tracking. Alerts are forwarded to staff for awareness of potential errors.

We use the newsletter as a resource for complying w/ JCAHO National Patient Safety Goals and the Medication Management standards.

review newsletter with nurses to make them more aware & to ensure they follow safe medication practices

Adding warning labels to certain drugs regarding look alike sound alike names is one of the many changes we have made based on this newsletter.

Look alike - Sound Alike medication arrangement in the pharmacy

Changed policies to reflect recommendations

test

Tall man lettering

I have presented examples found in the newsletter to classes given on the prevention of errors. I have also shared some of the info with many colleagues.

Has helped us maintain realistic expectations as we go live with our automated medication system.

Pca by proxy policies and education

Made changes in medication administration process, provided more references and safety checks.

we pulled all the "outdated" drug reference books, used many of the documents for updating our policies, used it as a reference for several educational inservices for nursing staff,

Have referred the information to other facilities that can use this information

Chqanges to Medication Admistration, Hugh Alert Medication and Controlled substances Procedures

I am a nurse educator and I use the information in the newsletter to enhance my instruction in the classroom as well as the clinical setting. I also share this information with my colleagues.

improvements in labeling and identification, and handling of medications

After the staff has read the articles it brings to mind things to change in there daily practice--like making sure to read all medication labels

I have presented information at all nursing orientations regarding medical errors that have been presented in the newsletters, PCA by Proxy, abbreviations etc.

I'm not currently in practice - work for VA NCPS, but I use the newsletter and website to verify and validate information and also for creative ideas.

I've used the PCA practical error-reduction strategies to help us with a FMECA on PCAs

Tallman labeling of computer listing of medications

The first issue we were able to have a plan in place before we received insulin and TB syringes (with the same color coding for the needles) so that they would not get mixed up.

The newsletter is posted each month. We review the medication errors and usually place at least one safety measure as suggested.

Provide data on medications that can affect the sesorum adversely in elderly patients.

they are printed and distributed to all licensed staff every month. feedback is positive and lively. they look forward to each issue.

I precept with new students and I use the news letter to show the possible errors that can happen. I also use the newsletter when I am teaching new nurses and make them aware or errors

sound alike drug stories used to inspire clarification before administration. Unacceptable abreviations stories help reinforce practice changes.

ideas for elimination of "Do not Use" abbreviations

I share the information with new employees as they come through nursing orientation.

policy changes

Revised PCA policy & procedure.

Our Medication Administration Policy will be updated with the information provided in this issue.

I give the info I obtain from this newsletter to my nursing staff since I am no longer to dispense medication as the DON.

training of new medication aides and new graduate students

PCA pumps....better explanation to pt and family.. I am more watchful of how it is being used

Helped front line nurses realize the importance of double checking orders and pt identification.

We share the information with all the clinical staff and it has helped our pharmacist with types of inservices

Our nurse management team has worked with Materials Management to ensure that syringes are ordered correctly, IV pumps and PCAs have gone through your checklist for safety. Medications are separated in stock areas and clearly labelled---we use Tall man lettering for these, Chemo drugs dispensed from Pharmacy were checked against warnings in your newsletter (Liposomals), oral syringes ordered for liquid medications sent from pharmacy.

labelling of products properly

As Risk Manager I frequently reference ISMP when investigating or making recommendations related to care provided at our facilities.

Instituted the Red Vest Program

Communicated ideas in a newsletter to the nursing staff of the organisation - acknowledged Intravenous pump item and cases of insulin errors

regularly use it to augment our safety meeting

PCA by proxy- we have created patient education brochure, created staff education, labeled PCA pumps with safety verbage etc. etc

PCA programming , is mentioned in our education sessions

My facility has made changes

I share this information with the students that I teach. I especially like the look/sound alike drugs that keep us on high alert.

Provided advice to colleages on practices as noted in this newsletter

Implementation of Do Not Use abbreviation policy

Assuring medication labeling is correct.

I've made suggestions, but they do not get adopted.

As Clinical Educator I find this a very helpful tool in making staff aware of high risk situations in every day practice and hopefully get them thinking more about patient safety

Implement policy and proceduresR/T med safety

I think sometimes staff do not realize the impact of or number of medication errors that are made , those that are reported and those that never get reported

I am in QI so it is very helpful to have ideas that initiate good discussioins.

We post this newsletter in our CCU breakroom to alert our staff of this very important information.

In regards to Broaselow Tape for childrens emergency dosing, after reading this newsletter, we editted the area related to dosing, and referred staff to standard calculations for medications to prevent errors with 2 different dosing recommendations.

I am a consultant and cover 37 hospitals in pennsylvania. I often use some of the best practices shared as i am working with my facilities.

I am passing the information on. Use it for implementation of some of the JCAHO safety goals.

I am a member of college faculty and we use the information in teaching our students safe medication practices.

I mentor a number of new graduates in the Critical Care Setting. I forward the newsletter to all of them, oast and present to help maintain their awareness.

New policy to use oral syringes for oral meds on peds unit

Distributed newsletter at ALL Nurse Staff Meetings, Posted on Community Education Bulletin Board, Distributed at Networking functions including ISMP url information.

I have sent suggestions to the pharmacy for strategies to reduce medication errors.

I teach senior level BSN students and have found many interesting points for discussion in class and in clinical post-conference. This also helps to teach the students that nursing education is an ongoing, life-long process ... thanks !

Taking syringe tips off syringes (before giving to parent for pediatric dosing) to prevent aspiration

Mainly distributing through our Medication Incident Review Group for information to demonstrate issues arising with mediction incidents are not perculair to our organsiation but are much wider!

I have requested sharpies be available to the nursing staff for labeling, but have not gotten any response. Many times, other staff request to use my sharpeie.

As a nurse manager I diligently read your information. I share it with all staff and when there is something relevant to my department I act on your suggestions.

Information was used to convince non-nursing administrators of the necessity for obtaining barcoding system for medication administration.

Use information when reviewing institutional errors to make widespread recommendations for change

As a staff educator, I have integrated information from your newsletters and error prevention materials into competencies for my organization.

I changed the abbreviations to comply with JACHO as written in one of your articles

We posted newsletter for staff to see, we already label meds and monitor this process.

developed do not use abbreviation list,

Just received the first newsletter

First reading

utalize as a teaching tool

helps with policy and procedure changes and endorsements, as current information, current practice.

they validate the changes made.

Distribute to staff, and point out recent changes in our current med policy that correlate

Info on PCA: use of updated medication references: I post info for other staff nurses to review: use if for educational purposes

We've changed how magnesium sulfate was prepared for nursing

Provide relevant information to nurses.

Incorporating some of the practices into protocol and form development

The PCA information was very helpful to implement safer practices in our workplace.

We changed our PCA Policy to include the recommended safety practices. Beefed up our look-alike, sound-alike safety precautions. Awareness of duplication therapy with medications in our medication reconciliation process. Reviewing our MAR structure to evaluate potential for errors. Legibility of physician's handwriting and clarification of same policy.

increased discussion and awareness of med error issues

Pass newsletter out to all directors to post on their units. Use in new nurse orientation as a teaching tool and resourse

I teach computerized documentation that includes emar and bar code scanning. I often use examples I read to make points about medication safety.

review existing policies and procedures for safe practices

As a nursing professor I incorporate the information into my lectures and skills labs

Being more alert to illegible orders, not assuming I know what the MD meant.

Used for ongoing education. Used article related to insulins for staff education. Signs about insulin

documentation, monitoring, use of abbreviations

Made changes in our PCA policy using reccommendations from your article on safe use of PCAs.

I have provided inservices to the OR personnel based on this issue

We used your information to support policy changes over the last two years in how we handle PCAs and high risk electrolyte solutions.

Label medications on surgical field

I am a clinical educator and use examples and articles to reinforce in-services and classes.

We have used the information in our efforts to create a facility specific "Do not use" list of abbreviations

make me more aware and careful with my practice

Iam a nursing clinical instructor and I use the information during post conference to increase the students awareness

Look alike sound alike drugs being stored in different locations.

One example followed up on the info regarding Baxter Pumps.

Warning labels on look alike sound alike drugs. Labeling and risk of above a consideration in additions to the Formulary. Guidelines and standard concentrations for high risk drugs in solution such as heparin, dopamine. Warnings printed on Medication Administration Records.

PCA pump selection

As Director of Nursing, I am responsible for policies and procedures used; we have used examples of errors to make procedure changes such as labeling everything opened

Recommending separating similar labels of different meds on the shelves in Pharmacy.

SPD and the OR have agreed to pilot the preparation and use of labels and markers in sterile packages for use on sterile fields - after evaluation and fine-tuning, we will begin to encourage implementation in other procedural areas.

Label medication containers on sterile fields

Used as subject for discussion in comittee meetings. Used as the bases for new or updated policies and procedures.

As a staff educator I consistently utilize the newsletter to strengthen the clinical staffs knowledge and awareness of medication practices

implemented computerized medication application

I am in LTC so really the information is put for discussion. THere has not been alot that has applied to us thus far.

What is taught in inservices and formal school of nursing examples

look-alike, sound-alike drugs for appropriate identification storing of injectible versus irrigation saline solution

Labeling of medications

Working on pain management assessment forms

When they spoke of the similarity of medications we went to our pharmacy people and we asked what we were doing. We told them of recommendations and some of those recommendations were modified and used for our facility

Moved sound alike / look aike drugs apart

included information in my classes with the new interns that I teach

As the Patient Care Saftey Officer I chair two Safety teams Nurse Advise-ERR is an excellent resourse for both teams

Content added to Nursing Orientation and discussed at Medication Safety Committee

ID identifiers, using examples of med errors for exercises at staff meetings for the unit

Use recommendations in designing local standards of practice, policies and procedures. Also examples are very good teaching material

We have a weekly newsletter called the bathroom news which we post in the staff bathroom.We use this to communicate new info to staff or to alert the staff about memos that are pertinent to practice. When the newsleeter arrives on my email I print a copy off and put it in the memo binders on the units and then make mention of the highlights in the bathroom news. I hope the staff reads the newsletter.

Share stories regarding other's errors and near misses at unit meetings so that we are all aware. Used many examples for our Independent double check training.

We use this newsletter for guidance when revising policies

discussed with staff to provide hightened awareness of new drugs, indications, potential for errors,

Currently distribute it to all my staff nurses. Not sure that the "frontline" nurse gets all the info that she needs on a daily basis but this definitely helps.

I use content from the newsletter in a course I teach (Nursing Issues: Leadership and Managment) and I post the newsletter on the course bulletin board.

We are more careful about look alike, sound alike medications. I also share the newsletter with other nurses and my daughter-in-law who is a LPN student.

Look-alike medications, esp. opthalmic drugs stored together, now separated. Used article and real-life example for educational purposes.

As a QI/Risk Manager, I distribute the newsletter to the nursing clinical departments. We also utilize it for discussion at department al meetings.

posted for staff to read

TO ENFORCE POLICIES THAT PEOPLE DO NOT FOLLOW

Have checked my workplace for IV Potassium Solution being stored on the work bench next to saline etc. Fortunately, it was being stored in its original box and away from the other IV solutins.

Review our own internal processes. To alert others of possible safety issues.

Abbreviations

Med reconcilation projects; review alerts and incorporate into policy/procedure/practice

Share in staff meetings for peers and staff.

iv labeling project in critical care utilizing tallman lettering

PCA procedure

Use articles for in-services and risk management

Developed a non-punitive reporting system and also a peer review group to review processes and near misses

pca pumps, policy,procedure, implimentation of new

Warnings were placed in Pharmacy order entry to warn pharmacists to check when enteral feeding is discontinued on patient with active insulin orders. Medication Safety Team is addressing intimidation in the workplace as a 2005 Goal. Ammonia inhalants removed from formulary. Hospital educated staff on using two patient identifiers, not to include room number. Hospital is addressing PCA issues These are only a few examples.

I chair our hospital's Nursing Practice Committee and have used the newsletter in guiding development of medication procedures

Information is passed on to all nursing staff.

Provided additional info to incorporate into development of staff inservice on High-Alert Medication Policy

pca alerts for patient use only

makes me more aware of dosage/ml. ratio to avoid overdosing or undermedicating a patient.

Used to update policies

Additions and changes to our new Pyxis / Automated Medication System Policy & Procedure.

awareness of medication errors

implementation of recommended strategies to prevent mistakes with similar sounding meds and similar appearing names

As a member of my hospital's Pharmacy and Therapeutics Service Team I have discussed information from the newsletter with others on the time and we have implemented several changes (ie tallman lettering, rearranged storage)

Policy revisions

provide additional verbal cautions to staff

Collaborate more closely with pharmacy. Have a spot on the agenda at our unit meetings, to review potential gaps in medication safety. We have posted copies of the newsletter on the unit communication board. It is discussed, and promoted. We also obtained large posters for staff education, which were mentioned in the newsletter.

Recommendations are shared with Nursing Leadership Council members and are also shared with Pharmacy for action in the Med Safety Team. We are doing alot of what your newsletter recommends. The newsletter is used to validate what we are already doing.

Checking of high risk drugs prior to administration.

post 2 copies on unit at med stations, at times use info for discussion at staff mtgs.

Really helps when something applies to a pt. I feel more confident that we are able to "serve and protect" our patients at the same time.

Changes in PCA policy, protocol and education.

New abbreviation list, look alike packages and names alerts

provide information to co-workers regarding medication awareness

I serve on the Medication Safety Council for my 3 hospital system. We use this newsletter to stay abreast of new issues in med safety!

Ideas are discussed in the Medication Utilization Meetings and decisions made to implement them.

I forward the newsletter to all of the BSN student nurses that I teach.

The publication is placed in the Nurse's Report room for all to read.

Policies to prevent future errors

As an Educator I share examples from the Newsletter with all new nursing employees and include some the information in weekly email tips

Although most changes are already in progress, and good publications and data help "dirve" our mission

Improved awareness of things to watch for in our ED.

changed PCA policy, use it as an educational format for staff

Information discussed and addressed in Patient Safety meetings and the nursing newsletter.

Reviewed by subcomittee of medication quality team and initiatives started due to suggestions.

I forward this letter to all ambulatory clinics. They have begun applying to their clinical areas......using nothing that does not come from out pharmacy, requiring labels

labeling perioperative meds and solutions

the newsletter comes to the risk manager and it is distributed to all nursing units and pharmacy. It is a standing item for the Patient Safety Council meeting

The newsletter provides good examples for why our facilities should be following the recommendations.

We have developed a process for reporting "near miss errors" and have convened a team to examine the medication administration processes here in hopes of reducing errors.

Clear documentation. requesting clarification

I use the information with my nursing students.

now have OmniCell for narcs

Inservices and computer teaching modules - have used parts of information or examples that you have given

After reading about the 1000 mL bags of sterile water being mistaken for IV bags, we changed our storage. We also used information form the newsletter to update our PCA polices.

We have used many of teh recommendations provided to change our practice. Thank you so much for this very useful newsletter.

We have a folder containing all of the newsletters. This is ongoing education.

Usually the information pertains to hospital settings. As we work in home care, the information is always good but may not be applicable.

Used examples in staff meetings to drive the need for preventive practices.

Double checks for high alert meds

changed the location of some meds in PYXIS to separate those with "look-a-like" labels and names

I provide this information in staff meetings to my staff and it has made for some interesting discussions! They are apalled at the things that can happen and now are more aware of why we do things.

utlizing the scenarios of what went wrong and then understanding why went wrong and how to change or improve practice

I am using the information to supplement the FMEA for surgical services on unlabled mediations in the sterile field.

Create "speed bumps" before some products can be used--i.e. ziplock baggies taped closed with alert stickers

Teaching and reinforcing prinicples of medication administration to students with examples in the newsletter

We now label unmarked syringes with labels made up beforehand

1. Update policy/procedure using this information. 2. As risk assessment guide tool. 3. Staff eduation and MD education, esp. legibility examples

We have completed our bar coded medication administration project. The newsletter is available to oru nursing staff to gain/enhance their knowledge base.

Change practice implementing information from newsletter.

Look alike ampules separated. Different dose of same drug separated.

Standard concentrations supported

Safety is part of daily team meeting

The mere drawing up of a medicine in a syringe and not labeling it -- reading about the tragic outcoes from other instances make us change our ways.

I share with all hospital nurse managers and pharmacy and also safety officer

as a manager, I ensure these articles are available to staff. discuss at monthly staff mtgs

I have circulated these to my nursing staff who have been deeply affected as to how a tragic error can occur when SIMPLE, STANDARD practices are not done routinely.

Add a line on MAR for nurse to indicate location fentanyl patch was placed.

Medication storage of look-a-like, sound-a-like drugs

issue from the newsletter are used to make proactive changes to practice and P&P at our hospital

Use of 2 identifiers with bedside glucose testing, omitted use of "scrap paper" for reporting glucose results and devised system for safer reporting of these results

I receive the newsletter and forward it to each clinical manager in the hospital. It also goes to all of our clinical educators and nsg directors (over 50 people total). Each of these individuals shares the info with their staff.

Investigate our practices to see if we all set up for similar problems.

Insulin is considered a high risk med, with look-alike, sound-alike confusion potential. After reading several of your alerts, one of our nursing practice leader worked with the pharmacy quality coordinator to come up with a storage system, that is low-tech but practical.

AS I teach in a school of nursing, it is important to teach our students safety principles when addressing med administration.

I have volunteered to be a designated subscriber, as the newsletter is not distributed in my hospital. I am waiting for a response from management.

altered staff on my unit to the different types of intravenous amphotericin

HAVE USE THIS IN OUR NEWSLETTER

Medication safety committee initatives

I forward the newsletter to nursing leadership and they distribute to their staff. I know they are read as staff will stop me and tell me of something interesting they read that heightened their awareness of how medication errors can be made. I've seen the newsletters posted on nursing units. So, although I do not know of specific instances of practice changes, I know that the information is being used individually.

SOME MEDICATIONS HAVE BEEN DELETED. SOME MEDICATIONS HAVE BEEN CHANGE IN THE DRAWERS, TO PREVENT CONFUSION.

Education of the staff is essential. I use many of your scenarios in class. Thanks

Situations involving look-alike / sound alike drugs prompted changes in the way we store these drugs.

PCA standardsa of care

I have not been the sole person to make changes, but the information is applied to appropriate situations and persons/committees etc,.

Information in newsletter validates reason for change in practice.

to enhance safe medication practice with students

We used the "Safeguarding automated Dispensing cabinets" article to guide our policy/procdure for use of our Documed (ADC).

review newsletter high lights at staff meetings and post newsletter on bulletin boards and in communication manuals

labeled itmes: food, and candies, Remember: knowledge is powerfull but,we all need to apply ourselves.Starting w/good practice habits could prevent alot of harm.

Labeling solutions on back tables

We revised our class on PCA utilizing information in newsletter

We review applicable drugs and issues in P&T and nursing staff mtgs.

Reminded me to think about common solutions that I use in my job and if they are easy to confuse.

1. labeling meds, 2. distribute alert messages to staff

We are setting up a new hospital and are using many of the examples from newsletter e.g. differentiating look-alike products.

I have used it as a basis for change. Espec the article about MD-RN communication.

Heighten awareness of how errors occur.

check it out

Look alikes/sound alikes--med drawer changes & alerts

Used as a reference for look-alike, sound-alike drug policy; assessing areas of our ambulatory practice for flammable solutions.

So far things mentioned we had already done.

Labeling all containers

Anesthesiologists were giving arguments that Diprovan (propofol) did not need to be labeled since it was the only white drug in use. The article on mix-ups between propofol and interlipids was used to convince them to change.

we use the information in our patient safety committee meetings and our Team Mangers meetings as well as our Pharmacy & Therapeutics committee. Some information is also shared with Medical Staff.

Separating and clearly identifying potentially dangerous sound alike and look alike drugs in stock. Removing several of these from floor stock whereby extra effort must be exerted to obtain the drugs.

Revise nursing policy/procedure for PCA, implemented use of near-label on PCA wand (labeled: Attention: Only the patient may press this button)

Various information has been used either to put in our communication book, used to supplement a medication inservice that I prepared, etc.

PCA Awareness

Checked for labelling. Made use of different size bottles.

We now store the TD & the TB vials in different locations, rather than side by side where they can easily be confused. A well seasoned ER nurse recently injected TB into the deltoid area, realizing her mistake almost as soon as it had been made, but not soon enough. She felt very guilty & humiliated. I had recently read an article you had about how easily these two are confused, copied it and gave it to her. She felt much better just knowing that she wasn't the only one who had made that error. It made me feel better to have helped her suffering self-esteem. There should be no shame in admitting one's honest error-that's the first step toward recognizing, and preventing a potential problem. To me, shaming a health care professional for making an honest mistake is like being foolish enough to cast the first stone, eventually you're going to get hit in the head with a rock too!!

We are working on changing the abbreviations used. We will be incorporating some of the information in our medication policy.

we read about the similiarity between brethine and methergine, and the hospital changed it's stock brethine to a bottle instead of an ampule

Information is given to staff via inservices and education

The newsletter has helped me to center on specific areas for staff education that relate to nursing in our area

I am a nursing instructor and the information in the newsletter provides my students and I with good material for clinical discussions and examples of what could result in improper handling of medications.

We have developed specific safety procedures for contrast media, in particular, based upon incidents reported in the newsletter. We have also implemented some of the recommendations for medication alerts on labels and in our automated medication delivery system. The Nurse AdvisERR is distributed to all clinical areas of the hospital and discussed in our medication safety meetings.

pyxis pop up to remind nursing how similar terb and methergine look

Reinforce changes re. labeling of syringes and the importance of clearly written orders.

Increase awareness of staff by discussing newsletter "stories" at unit meetings. Also, followed many of the practice changes as suggested in the newsletter.

I have used it to support practices we have or to help improve a practice.

We frequently use information from the newsletter in our own Pharmacy newsletter to keep staff informed of issues. We also discuss many of the topics at our Nurse Pharmacy meetings.

Support changes to medication practice guidelines

Emphasis on the double independent check for meds. Also, 2 identifiers reinforced.

I teach nursing fundamentals to my students and have had to strongly "urge" my co-workers to change their practice in some instances.

We have addressed surgical fires in our staff meeting; in Practice Council, we are discussing labelling solutions on the sterile field.

Used advice to create a policy on approved abbreviations in our institution

Creating medication safety education for staff nurses.

We consult for issues that should be addressed when writing a policy. We also use to educate staff on issues. The case scenarios make it real.

Will label 100% of the time vice 95%

Publish posters showing look alike drugs available in our own pharmacy--usually due to back orders. We do try to avoid this when making purchasing choices. Have implemented safer practices around PCA.

Included information in my orientation classes.

Will purchase learning materials suggested. Will plan an inservices anround topic suggested

moved meds

Procedural changes regarding dose verification was the most recent. I send the newsletter to all nurses on a montly basis and ask for feedback concerning certain sections. This stimulates thoughts and discussion, always a good thing. We performed FMECA on several medication processes as a result of this discussion that I expect has decreased risk in these areas.

double checks, non punitive system, therefore more reporting

We pay particular attention to medication labeling and vials which are same or similar in size, color, and design.

The newletter is part of our education requirements has alerted staff to erros that have occurred or might occur in practice

Updated list of dangerous abbreviations.

it reinforces why we must lable all of our allergy tray injections--energy trap--we can use over 100 syringes a day and labeling them is a pain but necessary

As an educator, I use the information to give examples of possible safety issues. Staff are surprised at how they can relate to some of the examples. It also reinforces that you can never be too careful. They are very slow to say, "that couldn't happen to me"

increase awareness to look alike labeling

The changes are increased caution when using certain drugs. I often put specific drug information cautions in my newsletter as well as posting the ISMP newsletter.

The news about the large bags of water being accidentally used for IV's and resulting in death of a patient was very helpful. Shortly after seeing that, Clinical Engenieering replaaced the heater/humidifier to our oxyhood and the new one used these large bags of water. I removed the system and we now use only nasal tongs for oxygen administration to newborns. I did not want those bags hanging near IV poles and potentially creating a problem for new babies.

The newsletter iformation was incoporated into a 4 hr. Medication Management Workshop for Home Health and Hospice nursing staff. Inservice addressed - Do not use Abbreviations, High Alrt/Problematic meds, Read Back, etc.

I am a staff nurse and am on several policy/procedure committees. I have frequently used this information in updating content of our documents.

As a nurse manager of 60 bed acute investigative unit, your newsletter has given me additional information to support the many changes that I have implemented.

Hospital has made changes with SALA drugs.

managers use this for inservices

Information is passed on to other departments where information is applicable

Added safe perioperative medication suggestions from 8/05 edition's 'Check it out' section to our orientation skills list.-

I have e-mailed my staff highlighted pertinent potential errors that are common--just to make them more aware and attentive. I refer to this ISMP Nurse Advise ERR for staff.

pharmacy has begun to utilize the tall man lettering for similar drugs on the shelf identification

I do chart audits and see many of the written problems. I now use them as teaching opportunities.

We have used the information on high alert medications to change our nursing practice.

our blocks are used only for the day. this also decreased costs because a smaller size marcaine/lidocaine are now purchased

I post the newsletter every time I receive it in our breakroom.

I have presented information from the newsletter to the RNs in my hospital. I am the Quality Manager and am always looking for ideas to improve the practices at our facility.

Review of P/P's with revisions. Group discussions. Publish info in our internal nursing newsletter.

Gave info to my nurse manager to include in staff meeting!!!

Label

As a home care nurse manager-to make sure this publication is available to any field staff. We are a small rural area and not many meds are administered by us but keeps us very well informed and educated and alert to mishaps or potential problems.

I am a director of home care. Most of your info is re: inpatient but I also feel the information is helpful for us to look at how we currently deal with potential hazards.

Have poster of newsletter to increase awareness. Setting is home health so specific instances not always relevant.

Label syringes with medication being administered. Double check calculations (always a safety practice)

We have a newsletter that goes out to the nurses with their pay statements and I often include info obtained from your newsletter. Thanks. I also teach some nursing courses at our local college and I share info with them as well. I think it is a wonderful newsletter.

I teach nursing continuing education and find the information helpful for the staff which I am instructing

Currently continue to work on eliminating abbreviations as recommended.

Our supervisor reads with us and discusses yoru newsletter at our nurse meetings.

Avoid abbreviations.

Pain management committee -- P/P changes

I work in industry (medical products) and have used information from your newsletter to provide safe medication practice to accounts. Multidose vial use, error prone abbrevs, multichannel infusion pumps, FMEA.

I developed a poster in-service on look alike meds in behavior health with positive results. A near miss was caught several weeks later.

Email alerts to collegues, present info to charge nurses in our ambulatory care clinics

writing out words instead of using abbreviations

I educate and encourage other RNs to label IVs, syringes, etc.

Symlin issues

Abbreviations (to avoid errors) will be addressed and changed to JCAHO suggestions and hospital wide suggestions

I include ideas found in the Advise-ERR in my monthly Process Improvement reports, and make suggestions to administration for areas where we can improve.

Increase discussion of previous medication errors among staff

I teach a class on documentation, and I use the newsletters as reference points for incoming staff.

as the clinical educator for an OB department, I use info presented in the newsletter as an educational resource. I love the newsletter!

Acceptance of verbal orders/use of abbreviations

I post a copy at work for colleagues to read

November 2003 issue talked about using units for IU--we have implemented this in our computer system. July 2003 issue talked about leaving IV solns in their wraps until use. We now place the labels on the overwraps rather than taking the bag out of the overwrap and labeling it. My staff no longer write on the IV bags themselves. We recently implemented use of a drug storage cabinet for after hours use. We were only going to label medications with with generic name until I read in the newsletter about keeping the brand name along with the generic as a form of double-check.

use it as continuing education for RNs on my unit to consider even the smallest error as something to learn from.

I am a member of the Medication Variance Committee in my organization and use some of the examples to help make policy and procedural changes here.

In policy.

We have compile a list of do not use abbreviations and are also reading back all telephone and verbal orders.

WE have warning signs on all PCA pumps to alert family/ friends not to push the PCA button for the unaware pt.

I assist in keeping policies updated and found the info helpful in doing this.

Tagging high-alert medications; communication with nursing staff regarding risks; communication with medical staff

Always label syringes before leaving med room; to be aware of look-alike meds; read labels

I'm in Staff Development, it is very pertinent to keep our orientation and every day staff training up to date. ISMP helps us to accomplish this. Nice to challenge us.

updated policies, procedures; incorporate newsletter during orientation and inform nurses how to subscribe

Revised our facility policy

I teach nursing and use the information to present up to date information to students

Objective information and examples make the staff feel less defensive,when presented as informational support.

I want to think that everyone is more careful after reading the information you send

narcotic safety ie, cosigning PCA syringes

A copy was given to our radiology nurses

Use w/staff education p&t committee

I read the examples to another staff member to increase awareness.

PCA issue was very informative and assisted me in altering some practises that occur on my floor

our hospital has used pt name and birthdate to id pts

we send it out regularly to all of our RNs; ideas have been very useful many times

Educate staff.

Used the article about look-alike med containers. We have changed the strength of one of the meds used in the OR.

separate like-labeled products

I use the examples in my lectures when I am in the classroom. When I refer to following the tubing to/from the patient to be certain that I have the right tubing, I refer to the dynamap inadvertantly connected to the IV tubing.

increase awareness

has brought about much discussion among the staff!

changing locations of med

developed list of do not use abr.

Made changes in medication administration policies

More careful labeling meds

Updated our abbreviations lists

are presently evaluating several label types for utilization in procedural suites- the operating room,endoscopy and pain services

1. Close call with TB injections. Near miss stopped for alomost a similar event. 2. Used for Educational topics that were timely.-to numberous to mention

Open discussion of nurse specific issues in a practice forum.

Decrease use of abbreviations in med profiles and orders

med error tracking

Double checking to make sure all containers and syringes are labeled.

ml vs cc medication awareness

Labeling unmarked syringes after drawing up solutions More careful when handling unmarked sterile cups and syringes that can't be labeled

Used the bar coding info to impact the GHS nursing/pharmacy consideration/development of new med delivery system under pilot.

Require labels on all solutions and medications, even if there is only one.

moving pre-mixed potassium minibags from regular minibags

Used as educational tool for nurses returning to practice.

your examples have reminded me to slow down and double check almost every med I give a patient. I double check the med I pull from the pyxis, in case it was put in the wrong container. I try to bring the med, unopened, to the pt room now so the pt can ask and see what they are getting.

Increased reporting without consequences. Increase in recognition of unsafe practice has caused the NICU I work in to put in a Pyxis which had not been felt to be necessary.

As a quality/risk management consultant, I am able to advise my clientele to subscribe to ISMP newsletters and to observe the recommended safety practices.

Our scanning process in place as well as our push to physician entry is something that our hospital is working on at this time.

Better emphasis on observation of the use of medications from a regulatory/enforcement perspective.

double checks

used to validate current P&P's relating to medication practices and medication errors

Illegible orders, transcription issues

I have incorporated it into my lectures with student nurses,interns that I meet with monthly for Insulin and medications for diabetes,unit inservices.

limiting use of certain abbreviations

Implemented safety measures related to PCA pumps.

Look alike sound alike lists for units. Rearranging automated dispensing machines to help minimize errors. Provided nursing inservice information on potential errors.

we are implementing emar (electronic medical record) and this newsletter provides prrof that we need to do something to insure better medication delivery!

We discuss topics from the newsletter at the medication review committee and have also used articles as part of educational programs to increase staff awareness

More accurately, the info has been used to support changes that are already underway

Increased frequency of chart reviews for potential medication order errors in the written order/transcribed order.

labeling meds

have removed many medications from easy access, or where they can become mixed up with other medications

I use the newlwtter for staff development.

I am a clinical resource for the infusion industry, and have shared the information with the sales force to help them understand the clinical issues involved with our products.

Inservices pointing out the problems with medications with similar-sounding names.

I work in Alzhiemers research

Things we teach students in skills lab

To empasize the importance of clear handwriting and the importance to question unclear orders.

I am more aware of medications and dosages in my practice. When I learn something new, I discuss it w/ colleagues. If I don't understand something, I go to our clinical education pharmacist.

staff meeting/safe practice focus

To make my staff aware of situations that we need to watch for.

changes in storing and dispensing some medications

To share with staff and help keep them up to date on practice issues.

we already were in process of making changes but newsletter reinforced our proposed changes, plus we posted the info as another resource for dept staff

Many ways but most recently increased awareness of dangerous abbreviations. I post the newsletter in my unit and the staff nurses have said it does increase awareness.

Engendered discussion

All clinical personnel have access to the newsletter and is shared by both RN and RPhs

We now stock pre mixed magnesium sulfate.

Developed a communication plan for medication errors.

increase staff awareness about medication safety

My main practice is in teaching. I use every newsletter with my students. The practice tips are used every time I supervise students administering medications.

POLICY CHANGES

used many of the examples in ongoing staff education, developing improved medication records

Improvement in practice, rather than direct changes. I posted the newsletters in the unit in which I worked and it seems to raise the awareness level of nurses of the need to be safe.

Increase staff awareness of medication related errors via patient safety training

We have a pharmacist on staff and it increases our discussions

Provide awareness to issues among colleagues.

Asked pharmacy to place items in different locations in Pyxis when labels are similar (Decadron and Tagamet). I post the newsletters for other nurses to read each month.

Reinforce our recent implementation of an electronic Medication Administration record

I teach pharmacology and share the information with my students from every newsletter. I passed the website to graduate students in our FNP program. All faculty subscribe to your newletter. Thank you. It is so helpful.

Passed onto other departments and managers

no longer use abbreviations such as cc; qd etc...have constructed an unacceptable abbreviations policy...and other patient safety policies

I participate on the med safety committee. I am the educator at my facility so I am constantly reminding staff to read their Nurse Advise-ERR letter.

We utilize the information as part of our surveyor staff education program. The information is distributed to our staff in order to keep them up to date regarding the standards of practice in various facility types.

We have placed large/colored labels on all our bottles of Ethyl Chloride warning users of the dangers of fire when used with cautery. We placed all cauteries in 1 closet with the same label so the MD's see it each time they remove a cautery.

PCA and look alike - sound alike drugs (increased awareness.)

I review articles at nursing meetings.

Shared information with the new nurses on orientation as well as with preceptors ie Dec 2004 issue "Santa's onto something..he checks his list twice, shouldn't we?" This is actually a policy that we have but your article reiterates the point of why we need to have "independent" double check.

Review recommendation for look alike sound alike medication storage. Reviewed nerd to double check TD and PPD ijections

I have used the newsletters to distribute information, but managment would be the ones to make changes.

As a director of pharmacy for our health region, I have used this tool to increase awareness and to supplement our risk management department in drawing attention to the great importance of augmenting our medication safety initiatives within our region.

SOUND ALIKE DRUGS SEPARATED

improved medication reconciliation. improved awreness of potential errors.

Put labels on everything.

support for NPSG

education of nursing staff for improvements in med administration and error prevention.

Storage of "look a like, sound a like" meds

Used examples shown in the newsletters to help nursing units identify problems in their areas.

Copies are given to nursing to use for education and being more aware of patient safety issues.

have used excerpts as basis for changes in a monthly PI newsletter to increase hospital awareness.

high alert drugs, sound alike-look alike

I am a CNO and we have separated items, post this newsletter at all nursing and Pharmacy areas, put red labels on things with alerts etc.

We cleaned out all of the "old" drug references, made changes to our PCA policies and practice, and many more.

I teach medical-surgical nursing and use this information a lot.

Working in OR we are changing to apply sterile stickers on our medications in the sterile field now.

abbreviation

Not yet!

Has helped us with labeling and storage of medications.

We review the newsletter at our QI Council meeting, where we may decide further staff education is needed or recommend that we review our current practices relative to the subject.

update policies and procedures

make us aware of near misses (we always post on the bulletin board for all to read)

Made a list of sound alike look alike drugs.

Newsletters are forwarded to Nurisng Education and used as part of ongoing education for nursing staff.

I'm involved with new employee orientation and use the information during the module on medication administration. Also, inform them about this newsletter.

Implemented double checks where they had previously been eliminated.

Medication storage, verification and increase knowledge

I have helped a group of surgeons start an ambluatory surgery center. I've used many of your suggestions to incorporate in our practice.

Educational information regarding medication error prevention is passed to nursing staff to stimulate a culture of safety.

No longer allow family to push the button on PCA pumps......many other changes!

aBBREVIATIONS AND cONC. ELECTROLYTES

I am responsibile for quality and risk management. We have seen an increase in medication errors at our hospice inpatient facility. I just recently came upon your newsletter and am distributing it to safe (the past 3 or 4 months). They have told me it is very good. Although not all medications are relevant to hospice and palliative care, they feel it is still helpful. We are measuring medication safety as part of a quality improvement initiative this year. Statistics will tell us how effective our interventions have been.

Not within the workplace, as there are specific players and committees which make such changes.

employee education

Re-inforced the need for legibility and do not use abbreviations and dosages. When I receive each issue, I forward it to all RNs at 2 surgery centers. Increases awareness even if the specific drugs are not in our formulary.

Difficult to answer, but each nurse and MD in the department are provided copies of the newsletter.

I proposed a recommendation in our PCA Protocol based on the newsletters last winter.

Have used it to make staff aware of importance with team coordination and communication.

Medication Safety Alerts have caused us to look at our practices and helped detect potential problems with other meds.

cascsade information to risk managers through out our organization. They in turn work with thw nurses in their local systems

I am an adjunct nursing clinical instructor. While teaching students about central dressing changes I added the step of verifying the products containing solutions were labelled and gave them the example I learned about from you. Clinical stories give a reality that reinforces the learning process.

engaging the patient and family

I teach in an ADN nursing program. This newsletter has been wonderful in making students aware of the responsibility we have to our patients to provide safe care. The cases discussed allow them to see the human error factor that exists and makes them realize as professionals we never reach the point of practice where we can stop being vigilant.

Promoting the reporting of medication errors. Improving the medication reconciliation process by requiring several nurses to review new monthly MARS prior to use.

I included the information on unsafe abbreviations and how to do an independent check in our unit newsletter. We post the newsletter on our staff educatin board.

I distribute copies for my coworkers to read and become better educated, my manger is not interested in finding interesting items to keep us current, so I just "Do It"

I am not in a clinical position but have posted copies of your newsletter for staff nurses to read.

As an educator I share this with the units I am responsible for, we discuss information at out safe medication committee, P&T committee, have changed/revised policies.

We care for people of many culture, the diversity article makes you realize why people think the way they do about their health care beliefs

PCA safety changes. ISPM was integrated into our mandatory self study for RNs and LPNs

Utilized by our Patient Safety Committee to revise policies and prepare education initiatives

We use the information in the newsletter to highlight possible medication mis-adventures and tighten our controls, use tall man lettering, make each other aware!

I have been able to include the info in classes I teach. I read the newsletters the second I get them, they are great.

I use these as a point of discussion as well as information shareing in staff meetings.

Written policies for near miss, look alike sound alike drugs,used some of the recommendations to assist in error prevention.

I send the newsletter to the out patient clinic nurses in the speciality clinic building.

Use in education

Have developed and distributed reference cards for Insulin

a form of chewable acetaminophen appeared on our ward, where the pill strength was hidden in the info text on the bottle in very small print. We petitioned our pharmacy department and were successful in having the product removed from the hospital.

Increasing the knowledge of my collegues who may not read the newsletter.

As unit educator, I always post the newsletter for all to see and point out safety concerns that esp impact our patient population

telling staff about the chages needed to protect our patients.

I teach in a practical nursing program. We are using this information when teaching pharm to our students. Helps them to move into the workplace with the most up to date information on preventing errors.

Have used this information with our Medication Administration Process Improvement Team- to bring about best practice.

We have the MD's go over their orders with RN's to make sure every order is a safe order and correct

Used information in teaching medication safety at skills days

I have not received the newsletter.

Labels have been changed, products have been substituted.

We have in-serviced our nurses from the information in the newsletters.

As a clinical educator I send out the newsletter to our nurses and support staff. Many were VERY interested in the recent issue with 'patch' medications and children. It changes some home practices of at least 4 staff, making their homes safer for children.

Have reprinted info in newsletter to share with my stafff

We have changed medications in our electronic dictionary to reflect tall man lettering.

I distribute to my peers and we incorporate your updates in our lecture material. I see them posted at the hospital

Actually ISMP did a survey in our facility, so the newsletter is a collaborative back up to the recommmendations that the surveyors proposed, such as addressing illegible orders, implementing order sets, etc.

Help to educate the doubting few as to the issues and even though we may not have had an incident it brings real life situation to think about how our processes would work.

Have used lists, posters etc. to educate staff/physicians.

use of abbreviations

putting a list of error prone symbols and abbreviations in the med rooms to increase awareness of mistakes that can be made (list of error prone sound alike look alike drugs too)

reading the patient's chart to ensure that the med fits the diagnosis

I post the newsletter for all to read on the unit.

provided examples to help others understand

Not formal changes, but clinical staff are informed and incorporate your suggestions into their practice.

"do not use" abbreviation list has been helpful We have alsoshared soem items in our company newsletter, when applicable

Examples are used in teaching; We have revised our PCA practices to incorporate safety measures suggested; IV pump programming issues.

anytime i find something that will help ( example: sound/look alike meds) i try to copy & post it, just to spread the word about potential trouble & make others more aware

When giving in-service programs to staffs of member hospitals

Use newsletter with Practical nurse students in preparation for clinical

we have the newletters in a folder all staff are required to read,and we share the newsletters with our clinic staff also.

I teach Pharmacology in A nursing program. I use the real-life examples in my lecture classes, as well as share the newsletter with the rest of the faculty

looked at changes in abbreviations

discuss with other staff the importance of considering ethnicity when interviewing and assessing patients especially for admission and discharge

These newsletters are shared with our Patient Safety/Quality department and other interdisciplinary areas where processes have been evaluated and chnaged

share my learning about PCA with my peers

Working in cardiology procedures, assisting EKG techs to properly LABEL solutions during cases! Working closely with our hospital pharmacist and using your newsletter along with JCAHO newsletter regarding medication safety and NPSG 2006 to reinforce those safety goals!

Reviewing systems with shift change narcotic checks. month end change over

Inform staff of potential problem areas

closer inspection of writtten orders prior to paperless system

I poste information about the enternal feeding on the board inthe med closet

I can't recall a specific example but I learn something with every issue and share with all my unit nurses.

On double pumps, always use one channel for TPN and one for IL

Teaching Pharmacology to nursing students

1. revising PCA policies and procedures. 2. posting relevant articles for staff regarding medication errors and prevention

I teach pharmacology to vocational nursing students and I regularly use ISMP to update my lectures and well as make sure the students are aware of unsafe practices and the way go make those change.

Always err on the side of caution rather than speed. Find another RN to double check your meds in questions, dosing calcs, etc.

pertinent information(eg. burns from MRI's with certain aluminum backed patches) triggered a discussion with our imaging department and then information is dispersed via unit newsletter which I put out once a month/ LPN's began to administer insulin sc on the unit and an independent double check was instituted which we intend to carry over to the RN's this fall

We do more teaching about PCA by proxy

abbreviations for some medications

Made me more aware of medication errors.

1. reading carefully as to what is flammable and what may be flammable. 2. labeling all medications that are inan unlabled syringe.

Not yet!

when checking insulin and other med calculations i now do it independently of the primary nurse

Stickers for name/dose alerts in the pyxxis machine. Moving same/similar name meds out of common access drawers.

Informing nurses about the Fentanyl patch

Near miss reporting, physicians printing orders, not using abbreviations, writing orders much more legible

However I have forwarded information to Pharmacy and Therapeutics Committee

facilitate the need for computerized MAR

I train medical students in chart documentation. The newsletters have provided many examples that make students aware of the need for legibility, proper clarification of prescribed meds, and proper use of approved abbreviations.

patient's safety

when trying to prevent narc. errors used suggestion to get rid of look alike containers/bottles Ex. Morphine 2mg/ml and 10mg/ml both were in look alike syringes...now one will be delivered in a vail and the other dose will be in the syringe

Have spoken to staff about 5 rights and reinforcing good practice. Review more occurrence reports with individual nurses

As reference in research paper prepared for discussion in my BSN class

I teach and I share this newsletter with my clinical instructors to share wtih their students.

Share with staff on units so they can recognize hazards..

As a quality advisor I am more aware of many safety concerns and stategies to prevent errors. I can share this with others in my work setting.

Newsletter information shared with Medical Center Medication Management Committee and Nursing Home nursing staff members. I use the newletters for educational purposes.

I have never seen the newsletter

Helps keep me up to date on new products /medications available. Refresh and update our knowledge

SALA strategies

Apply extra caution when giving medication. Looking up unfamilar meds. Checking BP before giving all HTN meds.

Distributed copies to staff and provided education hours for reading it and making suggestions for impropvement in our unit.

Made me more aware of meds that are in vials that look alike and I have pointed these meds out to RNs that I work with. We are all more aware of potential errors.

Taking certain meds out of the pyxis and making them pharmacy-only, such as potassium.

Insulin orders

I work in the clinical Quality department and based on the news we have implimented quality audits related to the content.

I distribute the newsletter to frontline staff

The way orders are written and the abbreviations used have been changed.

By reviewing with co-workers/peers, we have all expanded our knowledge base.

placed in a pharmacy binder for staff to access

Used as a reference tool. I just found out about newsletter this month, a nurse colleague mailed it to me. Suggest link to newsletter on AORN website.

Increase awareness to other staff nurses

We use the newsletter if applicable when making decisions on what to place in policies that we are implementing from the IHI and National Patient Safety Goals etc.

just to create more awareness

Information shared at Nursing QI meeting regarding oral syringes with oral medication being mistakenly administered IV. Decision made to switch to another oral syringe company, whose product was incompatible with IV tubing ports.

More aware of difficulty reading physicians writing and calling them to clarify it

removing some medications from stock, awareness of easily confused medications

More aware of sound alike and look alike drugs.

discussioon

labeling practices

I like to learn and appply update information to my practice which brings it better information and right things do it. I certainly adjust individually what I collected based on a data and reassess to provide the learning experience to meet those needs.

We are doing a specific study on safe medication practice on my unit.

make changes in transcription of orders

Our accepted abbreviations have been revised.

we are now putting labels on basins and medications used on the or sterile field

education - sharing mistakes

not yet

Being in homecare it does heighten my awareness of watching medications and treatments.

Share and derive practice guidelines

Team Meeting Discussion

Enjoy safety wires. Practical tips on practice! i.e. removing air bubbles, etc.

We have seen the ends of BP tubing/cuffs changed so they are not compatible with IV tubing

We have reviewed current policies and practices, tweaked where needed and sent but the info to all staff.

Print out for colleagues, distribution to ciritcal care transport crews, hospital nursing/pharmacy staff, share with managers

ensure solutions are clearly labelled

I have them as a "mandatory read" for all newly hired nurses to our facility. I have sent out flyers to nuursing staff using nurse Advise ERR information.

Labeling syringes

Your series on PCA pumps was very helpful. I used it to establish an education program that I do a competency check-off

Being part of a pharmacy committee to review and reduce med-errors

To be more aware of problems

It reminds one to double check on meds

Double Check

This is discussed in my monthly staff meeting with RN's

Labels are used on specimen cups to refrigerate solutions for wound care, such as half-strength H2O2/NS.

Share information with our management team and our interdisciplinary medication safety team. Use examples during our JCAHO tracer rounds to educate and heighten awarenes.

b. Make changes in my individual practice

19%

15%

Yes

58%

Increase awarness of most current practice

I don't do hands on patient care any longer.

Being more aware of unsafe, or potentially unsafe practices and applying them to my personal practice.

I have become more aware of drug interactions with food.

Double checking

I am the QA/RM Coordinator

Areas of focus for data collections & audit (quality improvement)

Increased awareness and more available information

I'm not in clinical practice- administration

More aware of potentail risks with medications errors, look alike bottles, students, etc.

It's made me very aware of how easy mistakes happen and the serious consequences mistakes have. I don't ever want to be an example of a mistake in ISMP!

becoming more aware, especially in situations where meds look alike, sound alike

I focus my educational programs/inservices more on prevention of errors than on analysis of errors.

Use the examples in the IV certification courses I teach to new employees.

as above

Check labels very carefully. Include information from the newsletters in education materials

Increased awareness of using technology for patient safety and adding resources to our Nursing Department Website.

I make sure that I have another nurse check all of my calculations and we double check each other. I am a team member on my facility's Medication Administration Safety Team.

I am on the patient safety committee and medication safety is always a front page topic.

I am not a direct patient care provider

several issues helped bring real examples to bedside nursing especially your focus on PCA pumps and the practice of PCA by proxy.

As a clinical educator I have used examples of errors from the newsletter in my teachings.

as above

Provide resources for assisting in our Clinical Quality Review process.

avoidance of dangerous abbreviations

The information provided has incresed my awareness of the many medications with similar sounding names.

Use caution when ordering drugs - sometimes hard to tell on computer whether they are long acting or not.

present information into presentations such as medication patches when discussing sedation and analgesia or physical assessment

write the medication out in full name, not just an abbreviated form

I have improved on reading labels (rather than depending on color of the bottle/cap/label) for identification, I label any fluid I put at the bedside.

See above

Much more diligent about checking 5 rights with medications

I incorporate the recommended checks to prevent medication errors in the clinical areas

I am much more aware of the potential dangers for patients related to the nursing profession. For example, I am much more diligent about following tubings and checking my medications. I LISTEN to patients complaints and think back to make sure there are medication related issues. I am overall more AWARE of the potential for medication errors in my practice.

DOUBLE CHECKING MY MEDICATIONS PRIOR TO GIVING. MAKING SURE I AM FOLLOWING 5 RIGHTS OF MED ADMINISTRATION

update department policies as per best practice and safety issues

As Quality Manager I am involved in Medication error reporting and it has been helpful in this area.

Reminders to remember to ALWAYS do the 5 rights, 3 checks, and step-back!

This comment may not necessarily be specific to this question, but I would like to remind the authors of NurseAdvise-ERR that all nurses do not work in orthodox clinical settings; i.e. hospitals. There are those of us who practice in the community who not only administer medications under all routes, but also delegate medication administration to unlicensed personnel. Having come from the orthodox clinical setting, I appreciate the emphasis on traditional practice concerns, but please do not forget that, nursing practice is not confined to hospitals.

Look for ways to facilitate improvement with various clinicians.

I share the newsletter with my Nursing Practice Council

increased awareness of safe medication practice

Verify med,container,etc. are what I want prior to using.

Helps in how I approach the subject with my nursing students

See above

I frequently use information for my classes on medication error prevention.

The "real life examples " help me have a visual picture and so help me to be More careful.

Increased level of awareness when delivering meds

makes me more aware of look alike/sound alike drugs

Utilizing stories and case examples as an education tool.

I have implemented information as both Educator and Nurse Manager.

I am the Risk Management and Patient Safety Coordinator

makes me cognizant of using the "5 Rights"

test

being more aware & knowlegable

I do not provide bedside care, but use the information as I described above in 6a.

I am a nursing educator and I use the materials to improve the content of orientation for newly hired nurses in our facility

Follow rules for writing medication orders

be more careful

more attention to various details of med administration, identification of patient and medication

Double checking the Insulin names

I've used examples from the Missing Medications article to help draft a nursing education piece.

labeling on sterile fields

The information has caused me to be more aware of constant changes in the critical area of health protection, especially as relates to medication adminitstration. The information has also resulted in my double and triple checking to ensure accuracy of prescribed doses, routes of adminitration, patient identification, and name of the medication.

More aware of possibility of errors.

i am the compliance officer of a hospital based homecare agency. i am also a nurse.

It increases my awareness of making an error but it is difficilut to make a change a chnage in the hospital because you have to go to a committee and making a practice change in a huge hos[ital like us takes years!!! TOO MANY LOOPS AND HOOPS TO JUMP INTO to make a hopital wide change!

See above. I am an advocate of PCOE now and look forward to the challenge in hopes the computerization of order entry will diminish adverse incidents.

Same as above.

become more aware of error causing situations, and take more time to look at possible situations

more safety awareness, similiar medication names, dosage that may be inappropriate

I am more aware now to watch for Lovenox when a pt has an epidural catheter...I came across an order for Lovenox with a pt with one and got it Dc'd..and more importantly the pt was not hurt and I did not hurt someone ...

I teach nursing students so I use some of the examples provides in your newsletter to stress med safety. I also encourage them to subscribe to it and put a link on my Blackboard course.

Made me more aware of the potential mistakes and how easy it would have been to prevent the med error in the first place.

IV guidelines are revised and reviewed using information from your newsletter. Pharmacy dept manager also uses ISMP alerts at monthly meetings with nursing.

and places and it is difficult to know the patients so I do not give meds until I have verified a person's identity

Increase awareness when connecting tubing

I am More Careful to check orders

have included safety tips in our nursing education courses

I am much more cautious with poorly written orders

Taking the time to familiarize with less often used drugs and double checking with patients on home medications/uses

Documentation of PRN effectiveness

The changes I have made is that I am more alert to avoid errors.

Makes me very aware of potetially devastating issues regarding meds/issues you discuss in your letter

Being very aware of labeling on all drugs in hospital and in Foster Home where my in law resides

see above

I teach clinical pharmacology in a School of Nursing. I use information from the Nurs-Advise-ERR in class manfrequently.

One example is that following an article on acetaminophen, I make my students givine acetaminophne in any form calculate the total amount of acentaminophen that the client receives daily.

There have been a few near misses that I had just read about and therefore was paying more attention

Promote wide distribution of ISMP newsletter information to heighten medication safety awareness. Encourage risk management/leadership decision makers/stakeholders to incorporate ISMP recommendations into organization practice.

I have heightened awareness of potentials for error.

I have attached a "mini sharpie" to my badge (purchased with personal funds) so it is always available to label syringes.

the alerts help remind me to never cut corners or assume anything... I go through my medication checks like we teach our new graduates.

Defines what to be cautious about, for example, insulin syringes, or trailing zeros

As above.

Always double check amounts in insulin syringe, no matter how small. always have a second person double check calculations of pediatric medications.

be aware of possible scenarios for med errors to occur.

As an educator I have used some the infromation in the post conference after clinical.

good information to teach

Will not use a couple of my favorite abbreviations

As an educator, I am aware of the changes, sometimes it is getting everyone else to do it, that is the hard part.

Increases my awareness.

By applying information disseminated via the newsletter as it pertains to patient care in the PACU and perioperative areas.

More cognizant of the potentials for errors and how they occur. Very careful about look-alike, sound-alikes if I'm in doubt I look it up. I read orders twice and read back and verify verbals.

READ LABELS MUCH MORE CAREFULLY-LABEL EVERYTHING

as above

Generally being more aware of medication safety issues.

I'm a nurse analyst for our Clinical Information System. I try to make sure the interface of the computer and clinician are as easy as possible to use. I continue to encourage requirements for reason for override on a potential ADR, but our administration has not warmed to the idea. They believe that too many warnings will impede the clinicians' thought processes.

Use independent double check for high alert medications.

Placed warning signs in areas where falmables are in use.

It made me more aware of the safety of labeling everything.

As an clinical specialist, I use your articles as supportive reading when I discuss medication errors in my place of work.

look at what I am doing, do not let distractions interupt me

Reading the articles has given me a better awareness of how easily mistakes can be made and it is important to utilize your resources as well as double check yourself and slow down. As nurses we are too concerned with time.

awareness and impove safety with my patients

I also work as a per diem supervisor in a rehab hospital and relay the information to staff as well as using it to make my practice safer

I am much more careful about checking drug labels.

I do not do clinical work. I work in quality. Information is used for my input into policy, procedure, patient safety, and for recommendations at the Pharmacy and Therapeutics Committee.

Teaching nurses about safety in patient care, especially with regard to pain.

Read labels more clearly. Unfortunately many ampules look alike. Different hospitals purchase from different companies so drug doses stocked in the unit pyxis vary.

Used as subject for discussion in comittee meetings. Used as the bases for new or updated policies and procedures.

Use information as part of my orientation for new nurses and also when re-educating nurses about medication administration.

see above

Double and triple check vials of meds that I am drawing up to give to a pt.

look-alike, sound-alike drugs for appropriate identification keep current drug book handy while working

JUSt an increased awareness of potential problems. I use tall man letters to clarify prescritions I write as appropriate

Eliminating use of abbreviations

More closely reading labels

personally,I am more mindful of the medications that my patients present with or are using for diffent conditions

Only keep one tourniquet at the lab station

Orientation curriculum

More awareness of specific problems like sound alike/look alike drugs

My role is clinical educator so when I read the newsletter I will mention items that have caught my eye with staff.

Ensure that all medication nurses are aware of the articles. I am a manager; therefore, will ensure that all nursing staff are aware of the discussions.

Makes me aware in everyday practice.

We especially liked the article on non punitive medication error reporting atmosphere

look up drugs and vocus on interactions with other drugs, discuss potential interactions with pharmacy and MD

Remember reading about similar packaging with some drugs and am very careful to check every med before administering it.

I am more aware of safety issues when dispensing medications.

As discussion points for different meetings.

changes in my own practice, increased knowledge to be a better pt advocate with doctors and medication

LABELING

Above

To make me conscienous about my medication administration practice

as above

I am risk manager and clinical coordinator. Increases my knowledge to share with others

Take high alert medications more seriously and double check!!

Heightened awareness of how accidents occur

I am more aware of errors that could occur, and it makes me more careful in providing my care

Reading about the errors makes me much more careful in all of my nursing practices.

I now insist on two patient identifiers when I take phone calls and when I enter orders.

More aware

pay more attention to the names of drugs as well as the proper dosing and administration. I fin the information about misleading names the most useful

I have always labeled my medications both on and off the field. I now have every one do a verbal "time out" when recieving the medication. I also do not put medication up on the field untill actually needed.

More attentive in checking meds/doses; more aware of potential for errors.

double checking look like sound like drugsa

effective in utilization of the 5 patient's rights: right med,dosage,route,patient,& time

Use material in classes I teach

Just more careful; take more time to read and double-check things.

More careful at double checking "everything"

awareness of medication errors

increased awareness of potential problem areas

Just being more aware

The newsletters have made me extra vigilant with certain drugs.

See above

Makes me more aware, and recognize my duty to patients extends beyond my shift and unit. As a result, I am a stronger advocate for clinical excellence.

Insuring that each syringe and vial is labelled.

increase awareness of several practice issues

Double check high alert medications

Read then research information and implement as best practice.

monitor meds more carefully

spend extra time reading look alike/sound alike medications; repeating all telephone/verbal MD orders, call MD's for order clarification if necessary.

I read labels more carefully, and check on any subtle discrepancy. I also use issues as a topic for post conference for BSN student nurses.

As an educator I include many of the examples in orienting new nurses

SAA

just makes me more aware

Evaluation of care provided during chart reviews.

No, but I have been practicing the safety standards already.

same as above

Use as a teaching tool with undergraduate BSN students

I read all of the examples of error which affirms my need to do all of the safety checks when delvering care in the complex systems of helath care facilities.

more aware of the errors that occur and with this awareness my practice has improved

I always use two forms of identification now - not just checking the ID band

Your monthly newsletter is a reminder for me to keep medication safety in mind each and every day.

Helps me to "think" and teach others--I am a supervisor.

Being aware of potential errors, how to prevent

Use examples in my new role as manager to emphasize vigilance.

Do more research and look up now before giving unknown or unfamiliar meds

I now more often double check calculations with a 2nd Rn particularly vasoactives.

With all the updates and emphasis on medication safety I find I more closely monitor the drugs I administer. I should check everything, even things I used to take for granted. It has made me more aware of pitfalls.

Changes in our P&Ps re: mediation administration in surgical services

Catch myself from just reaching in bin for vial, tab, etc. -- instead of reading

Reminds me to follow safe practice

Aware of look alike meds.

I have always thought drug companies should not name look alike labels and change colors to distinguish drugs from other drugs. Names of drugs should not be similar. We ar not short on words. My own 2 cents worth.

It increases your awareness of more medication look alike issues than I have ever personally encountered.

As co-chair of Nsg Rx group -- we use these copies every month, email to staff, hard copies available to all-- Thank you!!!

Increase awareness and focus--I do not take anything for granted!

Has made all more aware of importance to check, check and double check

mroe aware of checking and double checking

I use information gleaned from Nurse Advise-ERR as I re-educate staff who have made errors that could have been prevented. As I review MARs, doctor's orders, I am more mindful of potential pitfalls.

Continue to take MAR to bedside.

Teaching medication safety to my staff by providing this newsletter to all clinical areas

Re-enforces efforts that we're working on for Pt Safety (illegible handwriting, nonapproved abbreviations, etc.) Helps me learn from teh mistakes of others by reviewing the examples provided.

Try not to become automatic-be more conscientous

Hightened our awareness of patient safety and always reading labels.

As educator have highlightled relevant info for our area. Unfortunately very Adult focused. Would like more paediatric applicable

I am more aware of potential drug mix-ups, and more willing to ask physicians to spell drug names or give generic names in verbal orders, poor handwriting, etc.

All handwashing solutions are now wall mounted and labeled to prevent being confused as bottled medications.

Closely check labels for environmental hazzards ie, flammable etc.

more confidence with the inbuilt safety programs with PCA machines

Awareness, vigilance and caution with students in clinical areas.

makes me more aware of look alike drugs

More caution when administering medications

By being more attentive to medication administration, labels, indications, doses, routes, expiration dates, names of meds. Overall patient safety awareness.

TRY TO TAKE MORE TIME IN GIVING OUT THE MEDICATION. MAKING SURE THAT THE PATIENT IS THE CORRECT ONE. CHECKING THE ID BAND AND ASKING THE PATIENT TO SPELL HIS LAST NAME.

The situations and also the important points remind me constantly of the necessity to always check and recheck.

Analysis of practices that had resulted in errors, has increased awareness. More alert to these situations.

I am a Legal Nurse Consultant and appreciate being able to have this all incompassing information to site as a resource.

The information provided allows me to be more aware and improve my personal practice.

Have changed some of the abbreviations I routinely use.

same as above

Reconciling meds on pts admission to our unit

I will now be careful about labeling all products I use. I frequently start hep locks for CT scans and do not usually label my NS flush.

As I oversee nursing education we are always seeking ways to "get" information down to staff level. We review newsletter at nursing director and nurse manager meetings, distribute it at nursing PI meeting, email and make hard copies for units.

Double checking labels and med orders

Remembering to do right pt, right dose, right time, right route, right med, comes to mind.

I have discarded products in the past without labels.

Each article seems relevant. It impacts me directly--my staff have a binder with all of them. We use for inservices

Again to read labels, re-read and re-read one more time.

It makes nurses more aware of potential/actual problems, safety measures

More cognizant of labels/labelling and pt meds/interactions.

Newsletter is shared wiht all nursing staff.

Being adamant about everything needing a label.

When doing safety rounds look for unmarked bottles, syringes, and other products. When the info came out on new insulin checked with pharmacy to see if we had such a product in house.

Reminders to follow basic medication administration "rights" that we often take for granted. This practice has resulted in several near misses by simply slowing down and repeating the correct procedural steps.

REgularly read ISMP discuss with colleagues and recommend change to practice council.

I am much more aware of the importance of properly identifying my pt prior to med administration. I no longer just take for granted the pt will properly identify themselves.

More aware and take time to carefully check labels

When I write a prescription, I always state what the Rx is for.

The abbreviations highlighted are noted for correction. I am much more aware of the importance of clarifying directions for prescriptions when they leave our office.

All of the tips and information included in the newsletter have been useful in my practice.

become more cautious in checking my medications

I practice in home care many of these issues do not address self medication in the home

I find myself checking and double checking medications much more closely.

It keeps me up to date on what I need to watch out for while working with my students.

Although I have always labeled my meds and had double-checks performed if I felt it necessary, I am more conscientious about these practices. In addition, I am finding that I hold other nurses to these higher standards of practice based upon the situations described in the newsletter.

Slowing down and realizing that safe care is more efficient in time then the cost of an error. Double checks, being more intuned to look alike, sound alike drugs, discussions with staff and being proactive in their ideas on way to reduce errors.

Being more observant to armbands and checking with chart and pt.

I also work as an RN at a hospital and we have been struggling with the abgreviations list etc. I have to consciously think about those! For some of the equipment safety issues my facility implemented many of those in the past- good to see that we are doing pretty well there.

I check outdates, and for precipitate in the solution.

I now look for bar codes on all medications and am alarmed to find that it is absent on quite a few commonly used drugs in acute care.

SAA

Makes me more aware of potential problems

I include some of this information in the content of my monthly teaching new new RN hires.

Reviewed look a like sound alike drugs.

I absolutely abide by the do not use abbreviations and dangerous dose expressions here at the hospital as well as at a free clinic where I volunteer.

Never open sealed medications until I get to the bedside.

same as #6

Obtaining double checks on a lot of orders/medications

Read labels more closely

I am more aware of potential errors.

It has just made me more be aware on things that I do especially if there is a potential safety issue.

we require each pt to verify name and birthday before giving them allergy injections--we check, double check medication bottle # with their chart and then re-check dosage and correct arm

I am much more aware of areas of potential error after reading the newsletter. Thank you!

I am much more aware of problems which may occur due to systems inadequacies, staff training defecits and product labeling

I am not a nurse who administers medication anymore and thus have no opportunity to change my old practices.

Embracing / Enforcing hospital policy

educates nurses as to types of medication errors

Increasing awareness

more vigilant in checking labels on meds

I include the examples in my regularly scheduled Preventing Medical Errors presentations.

Assess that all medications on sterile field are labeled - even if only have one.

Communicate better in report

The newsletter information is very hands-on, practical and interesting and makes me to be much more alert to "near-miss" situations and potential errors.

see above

Increased awareness of herbal interactions

Read labels more, Notice if more than 1 vial comes for a single dose (Probably incorrect medication), read back all verbal/telephone orders

The newsletter makes me more aware of common mistakes to be avoided.

Make P/P's with safety in mind and suggestiosn for med error prevention.

I am working toward a management position and it is important to be aware of the issues in practice. It will make me a better manager when the time comes.

More awareness

Increased awareness of the importance of checking and double checking labels

See above

These articles reinforce the caution in me to always double-check and follow procedure to the letter.

Above

Makes me more alert to the importance of competency and knowledge of our staff and myself.

More careful consistently when double checking PCA dosing.

I always make a point to check all meds including flushes 2 times before administering to my patients.

Avoid abbreviations. Communicated with other staff about medicines that sound alike.

I have adopted many recommendations to accts based on information from yoru newsletter -- I like your "check it out" box of tips. Great newsletter.

More aware of med errors, use info to teach others, bring up examples in Administrative/operational meetings

by double checking medications that are used by myself

Just by being more aware of safety issues, I am reminded to be more cautious with medication administration.

Clarification of orders-repeated back drug and dose per verbal or telephone orders

I use examples from the monthly Advise-ERR to guide my practice in the right direction; I leaen from the mistakes outlined in the newsletter

I am not practicing at the moment but it makes me aware of things that can happen so that when I do practice I am more aware.

I have become even more consistent about labeling medications in syringes. I am also more consistent at using 2 forms of identification before doing treatments or giving meds.

In teaching my class, providing my staff with the newsletters to use and learn from.

Applying new info on individual drugs

keeps me up to date with advances and information

Taking errors seriously, no matter how minor, as an example of level of professionality in practise.

As supervisor of the IV team in our institution we discuss the pertinent articles from each issue which effect our practice.

Always take into account what I read and adapt as able.

It has made me think more about what I am doing

Not actually changes in my practice but has made me more cognizant of existing risks.

I am more aware about errors that may occur

Made me more aware of drug names and ways to help prevent medication errors from occuring.

pay much more attention

Practical and scenario-based examples are helpful to staff in increasing their level of understanding.

always verify correct med, usage, correct patient and dose

More careful connecting lines, etc. My hope is that other staff also use the information to improve their practice

Have been more cautious and aware of labels ,simular meds ect

increased overall awareness

I'm much more aware of similar labeling and how to devise protocols to prevent errors

It reinforces my practice of labeling syringes before I leave the med room.

made me much more aware of errors impact on pt. i share much of the info in staff meetings

As the clinical educator for the OR I try to share as much of the information that I can. I have approximately 10 minutes per day to present topics to the staff .

No changes in current practice becasue the type of enviroment I work in but I have made mental note for future practice

increase awareness

am just more aware of safety and litigation, so I question almost everything I do!

I label each and every med I have at the bedside using a patient's label and writing drug and dose on each label.

increased awareness, double & triple check

Product selections, changing systems for more safe errors, communication with team in Newsletter items that are directly related to practice in the ED setting..

presently nursing staff are involved in researching present practices and modifying to provide a safer patient care enviroment ie verifying the need for several medications,preps that are rarely utililzed.

Risk Manager-not at bedside, but helps with education

documentation and monitoring of documentation for legal issues

patient safety rounds

Get the scrub nurse to repeat back to me what she has received, ensured labeling is correct and make sure they (scrub) verbalizes same information to the physician receiving the drug.

as above

Same as above

Yse the PCA & safe medication administration info when orienting new staff and tell them that I will forward the email version each time it is received. Staff are accountable for review & process improvement based on Nurse Advise-ERR publications.

Already do all of the suggested practices. As teh educator I will make rounds to see that all solutions are labeled. Will provide an inservice on safe medication administration and incorporate the infomration in the NURSE Advise-ERR .

The increased awareness that I have of the types of errors and how they occur has made me more cautious and I think that I look at medications and the administration of them more carefully. I see other nurses just following physician orders without question. I now take the time to always look up medications that I am not familiar with and have on ocassion prevented an error that could have occured.

use info to increase awareness in education days

see #6a above

I look for possible errors and am quick to share the information with others.

Double checking medications with other nurses has become more of a way of life rather than a added practice.

more personally aware of error potentials therefore checks done more thoroughly

Illegible orders, transcription issues

more legible handwriting

More aware of potentioal problems in my practice, i.e. potassium solutions in ICU.

I am more cautious. I realize that a mistake can happen to anyone. It is not just "bad" nurses who make mistakes. We are all human and the systems developed by humans sometimes fail.

No longer directly involved in patient care.

Increased awareness and precautions.

look up medications more often

I feel more in tune with possible practice errors, and how to avoid them.

Each newsletter enforces being cautious, taking time and double checking

Adapting changes in procedures in Clinical Skills lab

Made me more aware of errors and the way to prevent them.

More cautious when reading physician medication orders. Questioning more often if unsure of the meds or of the spelling.

n/a

No longer controlling patient's "PCA" for them

While I do not pass medications, I do observe the nurses and remind them of the importance of using 2 patient identifiers. I have provided copies of the newsletter to the nurses.

I use the information I learn in a numerous ways. The information I learned about the needle colour changes, our director was not aware of the change. The information regarding barcoding for the future, the director was not aware.

As a newer nurse I am consistently checking my medications and checking doses. I work in a NICU and accuracy is VITAL as in any practice. I know that part of being a safe nurse is triple sometimes quadruple checking my meds!

same as above

It has caused me to be aware of possible medication confusion that I had not thought of

same as above, I'm specifically referring to labeling solutions on sterile field

I have deleted unapproved abbreviations from my practice, have used the newletter as a source of quality improvement ideas, used the newletter as an awareness and teaching tool for my staff.

I provide copies to all nurse managers to share with the staff. I have heard discussion and I'm sure it has caused staff to be more conscientious when administering meds.

Increased awareness and knowledge to educate staff.

provide education in instruction that I provide related to look-alike sound-alike meds, dangerous abbreviations, medication storage

more vigilant when reading physician orders, less likely to make assumptions

more diligence in my practice

It raises my awareness in medication safety AND I will start using some of the info in lectures that I prepare.

Starting being more diligent in reading medication labels before administering them. Verify written orders without hessitation prn.

I am an educator and use the information to teach staff nurses proper documentation and administration of medication on most inpatient units

I add the new content to what I am teaching and read (cite) the examples of errors or near misses in class.

have used information in the newsletter to make improvements to our electronic MAR and how it appears to the staff nurse to minimize errors.

The med safety committee follows your recommendations - QI process and collects datas med errors compared to staffing ratio- labeling errors and the list goes on

I have used them to evaluate the meds in our Pyxis and worked with Pharmacy to separate look alike/sound alike meds and reduced the variations in concentrations avail for each med.

Too soon. I've only received one copy.

check vials and orders much more carefully and never hesitate to ask doctor's to verify their written orders.

Aug 2004 issue "did you know..your patient's inhaler may be running on empty?" I keep a log of when I used my inhaler & I schedule refills....

I double and triple check when I dispense meds that I have read about

I have become a lot more aware of my writing and my use of abbreviations.

More aware of being careful with the medications and processes that are reported in the newsletter.

more visible labeling. rechecking labels before using anything.

improved medication reconciliation. improved awreness of potential errors.

check labels more carefully

I distribute throughout hospital

Being more aware of errors and the risk of them when I am doing pt care

check labels more

I've used examples from your newsletters as topics of discussion in Patient Safety and Medication Management classes.

I personally do not do clinical practice

ALWAYS teach the 5 rights. I know it is basic nursing skill, but I stress it with my orientees to assure patient safety

I am not "practicing" nursing, per se, but teach in the acute setting weekly.

Double check high risk medications and always have another nurse checking these also.

As a supervisor, has provided me with an invaluable tool to use in staff education and in discussion as topics relate to our organization processes

abbreviation

Initiated a Medication Safety Committee to review and modify the system to make it safer for patients and staff.

Not yet... just started reading this newsletter

Raised our awareness and caused us to be extra careful in particular situations because of things we have read in the newsletter.

Much more aware of look-alike, sound-alike meds, possibility of mixups that I didn't know were out there.

I now print all any orders that I receive and I do not hesitate to clarify an order.

check closely with sound alike drugs

By being aware of new practices and findings. Keeping my knowledge base current.

Makes me more vigilant

More alert to sound alike-look alike medications, use of pca pumps, common medication errors.

As a nurse educator, I frequently use information found in the newsletters for monthly educational programing

increased wariness and awareness of new and different and similar medications

increases awareness of medication errors-always match drug with diagnosis

Not embarrassed to have another nurse double check me.

Keying in to medications with similar sounding names, repeating unfamiliar drug names to the presciber or asking him/her to spell.

keeps you up to date.

Changing 30 year old habits in drugs names, doses, and symbols is difficult. Reading the ISMP articles re-inforces the need to do so.

Just by having the knowledge you are more aware

Now I make sure that any solutions I use in preassembled packages are labelled.

safety trumps speed

Taking more time to read manufacturer's inserts for warnings and alerts. Looking up drugs more often in reference books if I have infrequently administered them.

I changed how I do an Independent verification of medications. I do not use unsafe abbreviations and tell other nurses when they use unsafe abbreviations

I take more time with verbal telephone orders, I read back and re-read back if I am not sure.

as above

double checking to make sure meds are not mis-loaden in the Pyxis or mis labeled in the pharmacy.

using more than 5 rights for med checks, better understanding of human factors

Much more careful in transcribing orders and more careful in reading back phone orders from physicians

Generally more cautious on a day by day basis to verify patients' meds and reported doses vs prescribed doses.

I do not usually administer meds, so haven't put into personal practice

I am more aware of potential errors and learn from others findings.

As I orient new staff I quite often point out things to them that i have read in the newsletters Ie: the caps on syringes being a risk for injecting into a patients mouth when giving oral medication.

more alert to look carefully at medications and question the pharnmecey if I am unsure about a medication

it helped me to be aware of the different problems that exist with some medications.

see above comment

Used a reminder to double check all areas---

Double check meds with another RN if I have any questions

to be able to discuss outcome of medications + to calculate recommeded doses

Increased my compliance with labeling medications on the sterile field.

It allows me to be more careful in my own practice.

Have follow information thatI have read in newsletter.

More aware of medications that sound/look/lableled in a similar manner.

PCA update Help prevent med errors by slowing my pace

increased awareness of chance for error

alerts to patients

more aware of drugs available and how close the names do look and sound

I utilize the suggestions to prevent med errors.

See above

The knowledge that I have gained from Medication Safety alert newletter has help me employ some of the safety measures in my own practice. I utilize the newsletter as a resource in teaching staff who constitutes best practice

same as above

Increases my knowledge base and helps me develop information for programs

It helps me to realize that we are all human and by supporting each other we can change .

Makes me more aware of what is confusing to providers and nurses.

I am more acutely aware of double checks and correct strengths & doses of medications

I will be careful to consider ethnicity when assessing and to discuss findings with phyicians.

Drug awareness

As per above

conduct a PCA class

More aware of small errors

Take the time to read national patient safety goals related to medication safety and share them actively with my colleagues, including the physicians. Much more aware of past practices, and have taken corrective actions, to avoid future possible medication related incidents. Especially past practice of using MS for morphine or MgSo abbreviations, Mcg vs mc, trailing zero's, etc

Help grasp a understanding to the nursing field for my current nursing studies at SCC.

see above

re-double my efforts to provide error-free care. I also work with student nurses and use the newsletter to teach them and stimulate discussion.

ask others to independently check medications I draw up

being aware of changes in practice such as dropping trailing zeros in medication documentation, unacceptable abbreviations

I now write out the abreviations that are dangerous.

Be afraid of what you don't know--and then learn it. Don't guess, don't assume.

More aware of look-alike/sound-alike medications.

On those occasions when I do help with direct patient care I am much more diligent about reading medication labels even though 'I'm sure' of which drug I have in my hand!

Iam more careful.

above

I watch much more carefully for med errors now when I review charts and I follow up with my nurses more faithfully. I take it much more seriously than looking at these as a random error.

Made me more aware of medicaiton errors.

BE MORE AWARE OF HERBAL MEDS.

Marking of individual syringes

Be more careful with reading drug bottle labels. Keeping others informed.

I ask patients to state their name, open discussions about newsletter errors,posting and reading the up dates evey month

update my personal knowledge

New suggested abbreviations or long forms of words

I pay more attention when administering meds...I watch what is going on around me more such as not assuming the order is correct but always double checking it

Formulate cheat sheets and placed on the computerized medication administration cart as reminders and safety in medication administration.

I don't work in a clinical setting anymore, but if I did I would incorporate this info into my work setting. If I am teaching about meds, I do use the info

see above

During everyday Pt. care

Reminds us to pay attention to details such as cultural diffrences

This enhanced my safety alert knowledge

Double checking meds-especially anticoagulants, pain meds, cardiac meds. Paying more attention to pt's LOC before giving pain meds

I really take the time to make an extra check of the lable..especially when I am in a hurry.

Double check lettering and concentrations.

There was a story about an asthma pt who did not cap his inhaler and kept it in his pocket with loose change and wound up in the ER after he inhaled a dime.

writing more clearly

More aware of sound alike / look alike drugs

I am more aware of the need to double check the content of the progress note to be sure that the order coincides with the note.

It is easier for patient teaching.

become more aware of legible transcription

Just to be more mindful of potential errors. Look things up more.

I check dosage amt on vials twice I also teach student nurses & review with them some of the most interesting cases I have read in the newsletters, & we discuss poss ways of preventing those errors.

not familiar with the newsletter. have read only excerpts. Anything that can help reduce med errors interests me.

more awareness about mistaken meds when handwriting is bad

Has heightened my awareness of areas for possible error. Thanks.

as above

Asking doctors in the ER twice about meds ordered and making sure that what they wrote down is really what they want to give.

I double check

look alikes and sound alikes

I am always willing to change based on a data to meet thoss needs.

By using evidenced based practice methods, the RNs and MDs are collaborating by writing safer medication orders=dated and timed, and the RNs are made more aware of safe med. practices "Hand wasing in front of the patient before and after giving meds. etc

make changes in transcription of orders

I am more consciencious about repeating orders back to the person who gives them.

patient education at discharge

reinforced the fact that we should never assume

write my orders clearly, clarify orders unable to read, make sure med makes sense for my patient, repeat orders back to doctor if a telephone or verbal order.

not yet

Just have made myself very alert to labels and checking labels

I already routinely draw up medications one at a time and label them properly, but I will make sure I continue to do that. I will also be more aware to check labels on products to make sure they are flammable or not.

Be more diligent to look at medications and chemicals more closely.

More informed about like labeling product implemented change with IT MTX and IV VCR administration

When reading noting meds looking for errors that two nurses looking together or one nurse reading her med calculations to another will see the same error/do the same error. Need to leave them independently look/review med or calculation.

watch labels more clearly

JCACHO safety goals reinforced with Nurse Advise-ERR :) Advises current med safety knowledge to assist with precepting new staff

as above

PCA: better signs at patient bedside

Yes, I am a clinical Nurse specialist for the med-surg areas in my hospital. I use your tips and case studies to reinforce best practice with the nurses.

Watching for similar situations of med errors mentioned in the Nurse Advise Err and using any info mentioned to reduce med errors

to be more aware of problems

Double check all my labels

My team does label everything I think this new letter reinforces our practice

Position is nurse administration

c. Collaborate with another unit, professional discipline (e.g., pharmacists), or department to implement medication error prevention strategies

17%

21%

Yes

54%

If yes, please provide examples:

Have discussed article content with pharmacy

I chair the Pt. Safety Committee and we have used information to change practices in our hospital.

Implemented new forms for reporting of medication errors.

Medication error awareness through P&T Committee

Use the information to stimulate conversation and study between nursing and pharmacy departments.

I forward to the Pharm D and he as revised some practices.

Multidisciplinary rounds (RPh, PT, RD, RN, MD, RT, MSW, pt. & family)- examples used to spread awareness while on care / discharge rounds

Use of error prone abbreviations list

Patient safety

Items discussed at P&T

work with risk management and nursing administration to reduce chance of errors

See 1a

gave a national lecture at oNS

Added suggestions revisions to the Parenteral Drug Administration Manual that is used by the nurses.

share with ER, PACU, Open Heart Unit, Non-Invasive cardiac Diagnostic Unit

PHarmacy nursing committee and quality management activities

Worked with the clinical pharmacist on the insulin issues, Respiratory on safety for nebulizers.

See #6

We have a Medication Administration Safety Team in our facility and all of the departments that adminster meds have a member; we also have members who are independent from meds involved.

We have worked with pharmacists to improve by trying to move narcotics in the cabinets that look alike or sound alike, away from each other. Pharmacy is now using tall man lettering on their bins in pharmacy. The biggest reported error on our med variances is Lortab: either 5 given for 7.5 or 10 or just the reverse, too large a dose given as compared to what was ordered. This occurs because they are right beside each other in the cabinet,we do not have an automated system.

Our pharmacy and nursing services personnel use it.

Routinely collaborate with pharmacists to implememt medication safety practices.

Insulin and heparin in collaboration with pharmacy and many other strategies too numerous to list.

as above

Share with the "Safe Harbor Team" for Medication Safety

Work with Pharmacy and Quality Mgt on persistant use of range orders

discussions with pharmacy staff

Organization as a whole is addressing medication labeling in the sterile field

Working with pharmacy to incorporate standardized drip concentrations, as well as incorporating new infusion pumps with guardrail drug libraries

I have requested that hospital pharmacies post information in medication areas regarding high alert medications.

Much more collaboration has occurred with the pharmacy department on ensuring patient safety in our institution. Task forces with both RNs and Pharmacists have arisen to address any identified potential risks for our patients.

NEW DRUG OR ANY TOPIC ON DRUG, ABLE TO DISCUSS WITH PHARMACIST IF ANY IMPACT FOR MY UNIT.

review at monthly pharmacy and therpeutics meeting

We will bring to P&T the list of abreviations that are unacceptable

Regular dialog with the Pharmacy dept.

At the time of medication error discussion, a part focuses on prevention. This document has been used as reference.

Have been working with nursing practice council and pharmacy for medication issues such as PCA pump,look alike sound alikes, etc.

As adjunct information source to support ongoing efforts

Provide educational opportunities for staff to enhance awareness of potential problems.

See above

Frequently discussed in our Nurse/Pharmacy committee meetings, leading to recommendations for change

See a.

Again, in my teaching I stress the many strategies for medication error preventio.

More conversation/discussion w/pharmacy re: drug interactions, etc.

work closely with home infusion pharmacy

DIscuss at Nurse Pharmacy Committee

We have a meeting monthly with key people discussing the info. We call the committee SMAC

There is a risk of oversedation with DepoDur when uninformed staff administer sedatives ordered by physicians who may not be aware of the anesthesia used. The pharmacists were not aware of this problem and changed their drug screening process to include sedatives and sedating drugs such as phenergan.

Our committees that examine medication errors are multidi: pharmacy, physician, nursing, administration. We collaborate to share the information and implement strategies for prevention.

See 6.a. The newsletter also provides valid information to support recommended changes (such as our HFMEA on med reconciliation)

we've reviewed the newsletter during our monthly Med Squad meetings & have especially focused on the look alike sound alike meds & issues related to handwriting & abbreviations

Again, one example is adding warning labels to look alike sound alike drugs. We also collaborated with pharmacy to provide a list of insulins to all nursing units, which lists duration, peak, and time of day normally given.

The newsletter is distributed and discussed at our Pharmacy-Nursing Steering Committee meetings monthly.

yes, medication safety task force has made recommendations throughtout the hospital, including the reading of your newsletter.

6c

test

worked with pt safety group on new policies - abbreavitions, tall man lettering, PIXIS system

As above

particularly with high risk meds and others related to National Patient Safety Goals

as mentioned above

Send this info to all my clients

Included newsletter recommendations in our Medication Team

Review provided for medication error practice/study guides. Used examples of 'others' errors in teaching new nurse Interns

address as needed

We developed a safe order program to ensure that all patients receive the coorect med and dose ordered

I bring information to pharmacy to discuss

FMECA example as above

Primarily education of staff regarding some of the significant errors.

Tallman lettering

We review information at each Medication Safety Committee

Assisted/was very helpful in implementing a Fall Prevention program.

provides discussion between rehab and nursing.

it should! but the pharmacist too get the newsletter but we don't see as much changes in our clinical practice level!

See above. Stronger ties between the pharmacist and the nurse at the bedside have resulted with incresed communication.

Collaborative meetings with nursing, pharmacy and education

Working with a Provider group to develop best practices

Collaborated with pharmacy on PCA revisions.

Collaborate with Pharmacy to standardize method for checking chemotherapy.

meet with facility phamacy monthly regarding same medication destruction practice, new medications available with their s/e and desired outcomes

Information was shared with pharmacy. The articles help validate the newest standards from JCAHO.

Different ways to educate and inform

See above

Nurse Advisor ERR is a standing agenda item at our Medication Management Team meeting.

Nursing works very closely with pharmacy to carry safety initiatives and avoid patient medication errors.

via email to generate discussion

We have a medication Team that really benefits from this information so that we can incorporate in best practice for the staff.

Same as 6 above

As above.

Worked with Pharmacy on Medication Administration policy.

These recommendationa are discussed at Medication Use committee where clinical staff meet with pharmacy

Do this every time I visit a facility as consultant.

I have used the information for our medication PI teams. Use it to support some of the JCAHO Goals

I am on the rewrite committee for physician orders

TriCounty Educators quarterly meetings to trigger discussion on how organization is meeting medication safety initiatives, availble medication safety resources.

I have sent suggestions to the pharmacy for strategies to reduce medication errors.

Discussion with students - as above

Information provided to out Medicine Safety Team that consits of me as a senior nurse and two medicine safety pharamacists also the Medication Incident Review Group is multiprofessional consisting of professionals from medicine, nursing, pharmacy, risk management, paediatrics and clinicla governance

Found amyl nitrate popers in the amonia salts box. Found unit dose of valporic adic in the motrin box (they look identical). Pharmacy will order different brand.

this is minimally done but to some degree

Information is reviewed in multidiciplinary Medication Process Improvement Team meetings.

as above

We round robin the monthly letter to all personnel including the Pharmacist and the physician. It is part of our nursing monthly meeting on topics for discussion

using the alert to help with JCAHO recertification

Working with education to increase staff awareness

Charting which other disciplines use will be more consistent

As part of a county wide group of educators, we collaborate on what the literature says and what our individual hospitals are doing.

Bring to med use committee

Alot of involvement with pharmacy

Developed policy for locking intrathecal refill kits and catheter access kits in different locations so that the two weren't mixed up.

Via our hospital EMar committee

I take the monthly newsletter to the nursing units for a read and sign inservice. I take the current topics each month to the Safety Committee, P&T Committee, and Peer Review Committee for discussion. These reports go to the Board and the Medical Exec Committee. I also send to Risk Management and DON

discussed in our med error task force

CALL WITH ANY DISCREPENCIES, QUESTIONS ABOUT DOSAGES ORDERED THAT ARE GREATER THAN WHAT IS AVAILABLE IN UNIT BASED DOSES

share and discuss with Medication process improvement committee

I am part of a Medication safety team and we have done several of the suggestions that are also part of the JCAHO initiaves such as separaing look alike drugs in Critical care.

Our Medical Advisory Committee is very active in preventing med errors. I have used the newsletter to alert the committee of possible problems.

nursing students and skills labs

MD's were cautioned to make orders more legible. Nursing staff made aware of look alike, sound alike meds.

discussion, rely info to other professionals about what I had learned. ie. flammability of lacri-lube.

info on depodur

medical practices committees to develop Do Not Use Abbreviations, High Risk Medication lists, and med variance data collection.

with other IT specialists and staff on an ad hoc basis

Talking about all the options to meet the new safety standards

We make copies of Nurse Advis-ERR and distribute throughout the facility as well as review in our Nurse Practice Committee and Medication \Safety Team.

Above policy changes were made in committee with a multidisciplinary team which included nursing, pharmacy, physicians and quality/safety input.

Talked with Chief Pharmacist.

I give this newsletter to the pharmacy and to respiratory and other departments when it applies to something they do.

Our Pharmacist also gets the news letter and is able to give examples of articles he has read. He gives me different examples to use and uses in his own presentations as well.

Helps the Staff Development Coordinator with planning her inservices.

as above

I am a member of the multidisciplinary Patient Safety Team where we discuss issues in ISMP and write and implement an Action Plan when needed.

Input at Pharmacy and Therapeutics Committee. Making policy recommendations.

Faculty for PCA Consensus Conference

Eliminating trailing zeros

see above

OR (above)

I found out about your newsletter from a nurse consultant with Omnicare Pharmacy. Our pharmacy services are now with another firm and I have shared the newsletter with the current nurse consultant. No updated feedback at this time.

Share with other educators and nurse specialist when developing competency packets for unit staff

see above

work with pharmacy on more standardization of coumadin dosages as well as development of a use of coumadin protocol

Collaborate with pharmacy regularly on each published safety issue to implement safety sttategies proactivley to prevent situations from occurring.

I distribute these newsletters to the various nursing units for them to read

At our facility we present out needs and requests @ ECOPS and FAAT. with having some of this information we are able to better present our position on certain matters.

Was provided laminated page of abbreviayions not to use.

I am an occupational health nurse and do not practice in the hospital setting. When I found this site, I informed my relatives who both practice in hospital settings and look forward to each issue to discuss in their workplaces.

use info in my unit cnferences with the nursing stafd

Through our Safety teams and the Nurse managers feature the newsletter in Nurses meetings

As above, discuss with Pharmacy

Work with pharmacy on standards of practice

We share the newsletter every month at our Medication Safety Team Meeting. We then share the newsletter with all nursing staff and pull out individual pertinent examples!

Pharmacisits works closely with nursing and also receives this newsletter and has talked about it being reenforcing to policies.

see above

Suggestions about med labeling were forwarded to pharmacy.

We are working with the pharmacist to print up a standard dose guide for some IV meds that we commonly give to our pediatric patients.

Aggregate med team (inc. pharmacy) regularly review info in ISMP newsletters

Distribute copies to pharmacist; utilize in our medication event review subcommittee.

asking pharmacy about changes with medications and getting policy rewritten/updated.

PREFILLED SYRINGES PHARMACY NOT CONVINCED NECESSARY

Above

identified problems with new insuling protocol

used by patient safety committee to compare our practice with others measuring up with JCAHO patient safety practices.

Has greatly opened communications between nursing and pharmacy

Every issue is discussed at our Medication Safety Team meeting.

Working with Pharmacy and QI department in development and training of High-Alert Medication Policy, mediaction error reporting.

Use as a monthly educational credit items

double checking computerized printouts of meds. w/pharmacy

Interdisciplinary team for the new Pyxis / Automated Medication System.

frequesnt interaction with pharmacist regarding safe system designs

see answer to 6a

Through monthly medication safety meetings

believe these are coming from our pharmacy sources who are on the same page.

As soon as I read the current issue, I discuss it with the pharmacy staff and we are able to brainstorm to come up with strategies to address potentials for error. For example, whenever there is an order for an "on call to OR" medication, previously it was listed in the electronic MAR as a "prn" dose. Now it is listed for a specfic time. That way there is a double check and no doses are missed. Just the open attitude across departments improves communication, thereby improving safety.

Use of BCMA and Omnicell.

On occassion am able to discuss some of what I learn c our Pharmacist and I feel we work well together c this influx of information.

We have found that many of the med safety projects we are working on are highligted in this newsletter and we have a reference for addressing all the issues with that particular item.

Collaborated with pharmacy as well as all nursing units to develop new PCA policy/Procedure/Education.

students and new grads carefully precepted

The pharmacists and nurses on our Med Safety Council work very closely together.

Ideas are discussed in the Medication Utilization Meetings and decisions made to implement them.

Sharing information with the Imaging Department has been helpful.

Hospital has an interdisciplinary Medication error Prevention committee that uses the info to devise hospital-specific strategies.

I chair our medication safety group which includes nursing, pharmacy, medical director, risk manager, and QI.

As part of the Medication Safety Committee, this is pertinent to some of the issues we are trying to resolve

This is another good education tool- that goes across service lines

I give a copy of this to the director of pharmacy, have used it as double check are we doing this?

Patient Safety meeting, Root Cause Analysis teams, Process Improvement projects

risk management, other operating rooms within our health care system

The newsletter increases awareness for many nurses that work a secondary job code in acute care settings.

discussed during pt safety meetings with all members.

Consultation with our consulting pharmacists is part of our standard operations.

"black box" warnings, chemo advisories have kept us aware of changes in other areas that can impact our work in endoscopy

I work with our pharmacists all the time and your information on high risk drugs helped us update our policy.

Implementing changes in pharmacy re: look alike and sound alike with colored labels and tall man

Good newsletter

In-unit pharmacists for resource and cost knowledge of drugs.

I have been working on requirements for drip orders ie: starting rate and max rates.

Seems I usually take information to the anesthesia nurses and pharmacy for their information

Use information discussesd during committee on patient safety meeting; change policies in collaboration with pharmacy dept

Trying to work with CRNA's and OR staff to get them to adhere to safe practice standards--this is hard

Information is also reviewed in conjunction with the pharmacist to implement opportunities for improvement

Pharmacy to separate look alilke drugs and different drug dosage.

Stimulates/supports changes

Nursing and pharmacy collaborate on every patient

They've (the pharmacy) developed a pamphlet of herbal medicines and their effects. I work in a surgery center and this is helpful.

Our pharmacy dept has been glad this information is out and is excellent communication tool.

providing inservices on safe medication admin also decreases number of times something is transcribed

I have shared these with other DNS' in our company.

As a nurse educator in a community hospital we are using this publication ot enhance our efforts surrouding medicaiton safety at all levels. Thank you for this timely and helpful newsletter. Please continue!

Encourage MAR to bedside -- can't wait till IT and barcoding become mandatory.

Coordinate efforts at Patient Safety meetings with the info in the newletter with all clinical areas like the Rule of 6 with E.D. and Medical/Surgical units.

This newsletter also goes to our Pharmacy Staff, Nsg, Pharmacy Quality Pgms meet regularly to review and discuss problem issues.

Use tall man lettering in our Pyxis system

We worked collaboratively with pharmacy to creat a library for our smart infusion pumps. We also developed a reference for IV infusions that can be given on Critical Care with standard concentrations, dosing and nursing implications (administration, monitoring, etc)

Currently involved in 5 R,s campaign

Discussed alternate sites for injection of lovenox and heparin SQ

Worked collaboratively with pharmacy to change glass bottles to plastic bags for epidural infusions to prevent creating a vent resulting in interrpution of a closed system

THERE IS A COMMITTE IN PLACE TO DISCUSS CHANGES

I serve on the nursing/pharmacy committee and aslo P and T. Your information is excellent.

Drug storage strategies. Prompts discussion among units and departments as to error prevention.

use in meds management PI team

I provide this information to attorneys litigating cases in turn educating the public.

Information assists with developing policies and protocols to assure patient safety

Have worked with our off-site pharmacy

same as above

shared information with other staff developers throughout our institution who are working to reduce medication errors and near misses

Pharmacy has been very helpful wiht implementing ideas to prevent errros. We can go to them with proof in our hands and tel them why we want things done certain ways.

As a result of recent issue on Pyxis, nursing dept is working with pharmacy on improvements.

Working with pharmacy on medication reconciliation

I have copied the August 2005 advisory for our OR staff

Yes, just went to a meeting about vincristine.

I work in a long term care setting, our issues are different but basic prinicples are same.

Stimulates dialogue, Medication Safety team organization, pharmacist to nursing dept meetings--discussion re: specific unit errors

Nursing surveys and content from "check it out" and "safety wires" used in educational programs.

We have our own pharmacist in ED now.

Newsletter is discussed at our nursing/pharmacy CEQI mtg.

In addition to work with the anesthesiologists, it has resulted in a lot of work with pharmacy.

Work with Consultant Pharmacist and Medical Staff to implement safe medication practices.

PCA Task Group (interdisciplinary) started 6/05 with anesthesia, nursing and pharmacy to address PCA issues.

I am eager to share what I learned from your newsletter with colleagues. There has not been one I have read yet that I have not learned from.

We are trying to develop a medication policy for our physician practice. This information will help us.

The hospital I work at has used nursing, doctors, and pharmacists to get rid of many abbreviations used in medication orders that can lead to errors (such as <,>,QD,gtt,etc.)

see above

I have passed along your information to our pharmacology instructor.

As the leader of our medication safety team, I have made it a point to discuss the information in the newsletter in these meetings and to implement as many interventions as possible. At the very least, the newsletter are used to stimulate our thinking and awareness of patient safety issues and their potential here.

see above

Many of these alerts have been discussed at Nurse-Pharmacy Task Force, Patient Safety and Critical Care Committee and practices revised and/or implemented.

Nursing works closely with the pharmacy. This AdviseERR is part of our minutes.

Have implemented use of Pharmacy Robots at both of our Facilities as well as in the middle of implementing barcoding and scanning medication delivery

We are currently revising our MARs to standardize content based on best practice recommendations (eg tall man lettering) for 13 sites and 3 HIS systems

I use the flyers in class to read examples of the things that CAN happen

Med reconciliation PCA pumps Smart pumps Labelling rx. this month very good Doing fire testing on waterless hand sanitizers.

Will communicate with Pharmacy on any issues related to meds in the crashcarts and Pyxis.

discuss in ADE potential for harm here at our organization.

Sound alike/look alike medication storage in every medication area, especially in perioperative services.

working with fmea group

In our ASC we route monthly NurseAdvise-Err to all RN's for their review and initial routing slip

As in question 6.

Work with physicians & their office staff to decrease their liability exposure, so various strategies to reduce medication errors in ambulatory settings have been incorporated into our strategies.

Unit Educators share info

Report articles to a Collaborative Care Council, so examples can be shared across our health care team.

pharmacy- nursing committees

I am a longstanding member of McGill University Health Centre (MUHC) Adult Site Medication Administration Policy commmittee (a nurse-harmacist committee)and the primary educator for medication administration practices. Once again, your newsletter has given me additional information to support the changes that are implemented. I am the member who has the "membership" to ISMP and whose responsibility is to inform the committee of any pertinent inforamtion ISMP sharew with me.

2004 Hospital Policy enforced

Only by sharing information

Through discussion at our Meds Use Interdisciplinary team meetings.

Anaphylactic reaction protocol instituted.

I have made several suggestions to pharmacy r/t "look alike drug containers" that could cause errors, discussed need for RNinformation r/t generalized allergies--like "sulfa"

Medication Committee (multidisciplinary of nursing, phsrmacy and EMS) has reviewed issues and incorporated ideas

Often meet with pharmacy staff about findings from the chart audits. I ask questions and point out areas where I find difficulties.

Hospital wide initiative

Auto med dispensing project.

TQM already in place!! (Medication Error Team)

We are going to initiate having a pharmacist evaluate our patient's med list for discrepancies/interactions.

Many of the topics are changes/discussion that our Nsg/Pharm committee has discussed/recommended for change.

After reading your newsletter on labeling solutions, I discussed with a technologist reasons why labeling did not occur (on tray setups). Fortunately, we have had no issues...however the added measure helps to ensure safety. I am happy to see labeling in being instituted in our facility.

I have more than one job and I use the info in each of my areas of employment.

Discussed availability of certain medications in Pyxis and making sure similar names medications are in separate Pyxis locations.

Weight based medicine -- in ER we "guestimate" weight -- we now make sure that only doses in ER are this way by requiring MDs to write weight based meds as mg/kg upstairs so it requires nursing staff get an actual weight on pts arrival.

Again collaborated with behavior health pharmacist on poster.

Topics discussed at bi-monthly Multidisciplinary Medication Safety Committee; Newsletters posted to Nursing Intranet -- incorporated into Nursing Orientation.

Our medication safety committee uses this newsletter to alert us to risky practices, and amend our practice accordingly.

Pharmacy/Nsg staff/Diabetes nurse (CDE) worked together to roll out safety precautions for Symlin proactively.

As the P.I. Liaison for my unit, I use the information gleaned from the newsletter when brainstorming with other departments and disciplines.

I use these examples when discussing the importance of patient safty with others

Am working on a multidisciplinary team to improve information exchanges during handoffs.

Increased awareness for the development and design of user interfaces for medical devices

work with pharmacy, anesthesia, M.D.'s and nursing staff to develop facility specific changes to improve medication safety. Also working with clinical engineering, nursing staff and department directors to purchase new, safer, IV infusion/PCA pumps.

Pharm - checking ID band for Pt name & FIN #.

If I read things that are immediately relevant, discuss with pharmacy staff.

Identifying problem areas

See "a"

Discuss with pharmacy and see how we can change. Issue is that our hospital is not supportive of change and inquiry.

We have implemented medications error prevention strategies facility wide

Again, communication with medical staff and pharmacy staff in reviews of our formulary and storage practices (tagging high-alert medications) in our drug room and pharmacy.

Collaborate with pharmacists for IV compatabilities or when questioning dosage

Have a medication error prevention QIT with representation by many units including Pharmacy

Made me ask questions and become more involved with being part of a interdisciplinary team.

collaborated with sister facility and risk management.

It makes every staff and collaborators see one vision="preventing errors".

It makes every staff and collaborators see one vision="preventing errors".

Usually issue has been addressed previously but use as a review to ensure we remember why we do whatever in this manner.

pharmacy r/t narcotic practices

Implemented smart pump technology in the NICU

Used frequently in practice discussions.

I routinely check w/ the hospital pharmasist on chemical matters

1:1 discussion with pharmacist or topics for discussion at inter-discliplnary QI meeting

are presently reviewing options with pharmacy for increased unit dosing in the procedural areas, administration is researching options for increased technology for order entry,point of care documentation,inventory levels and others

high risk medications and storage, labeling

med error tracking

Have meds listed in our automatic dispensing system (pyxis) more easy to read. Some have extra wording that is confusing or have several different meanings

Team education

Nurse Pharmacy Comittee & IV Drug guideline committee work

Will sk pharmacy to visit the OR and make rounds with the educator or manager.

Large discussion among our chemo safety task force about vincristine and processes in place to avoid inadvertant intrathecal admin

When we had a look alike error (2 meds in narcotic cabinet in 1 mL vials) I advised changing the 10mg Morphine in the 1 mL vial to a 2 mg/mL tubex container.

Same as above.

Informed our nursing students about the newsletter, especially the ones just graduating, as a way to help themselves prevent med errors.

I am receiving this newsletter even though I don't want it. It goes to an entire email list of RNPs/RNs who didn't request it. Sender says he can't delete individual names. Argh !! Therefore it is SPAM to me.

Information is shared across multiple programs (enforcement) and questions shared with our pharmacy unit, to gain clarification and improve understanding.

new work with qa team

collaborate with our Pharmacy division to ensure medication practices and medication error monitoring are in synch with current standards of practice

Illegible orders, transcription issues

Discuss strategies with the Director of Pharmacy to ensure safety practices are up to standard.

In writing new sets of standing orders, we are now including not just the dose, but the drip rate for the machine. We have changed the concentration of some of our medications (pitocin) to make the dose to drip rate calculation easier.

See #6 above.

Again, use is supportive to ongoing collaborative efforts

visit with pharmacists

Have made some positive changes along with our pharmacy dept to increase positive outcomes.

As errors were reported they were reviewed with other memebers of the team to allow for discussion and awareness.

Same as above.

We no longer allow vials of potassium to be kept in the chemo hood next to other drugs. It would be too easy to draw up a dose and inadvertently give it IVP. We have adopted a non-blame atmosphere so that employees will feel free to report a med error, or a near miss, so that we can discuss strategies for prevention.

n/a

I took your article regarding the look alike names to our pharmacist. Our MARs now have the same format of caps for drugs.

share information with other risk managers and nursing admin professionals

patient identification

collaborated w QI director

I have worked with Pharmacy and our MDs to discuss the need for change or potentials for errors in administration.

Our pharmacist has always been a great resource. With all the new Medication Standards from JCAHO, the newsletter has reinforced some issues and increased policy formation and training.

as above

Have sent your newsletter to all nursing areas for information to be receivd by the nursing staff.

implement how meds that sound alike look-alike are stored.

POLICY CHANGES

used information in the development of safe medication administration practices, policy and procedure

I very frequently forward your newsletter to other co-workers across disciplines to share knowledge.

Topics presented are incorporated into our Patient Safety committee meeting agendas as appropriate

our P & T committee has used some of the information

Patient controlled analgesia

See 6a above.

Nursing and pharmcy jointly review medication errors and implement changes to prevent future occurences. Such as the correct bar code labeling of medications and what nurses need to do if they find medications incorrectly bar coded. We have identified incorrectly stocked medications in our accudose machines via the eMAR system and corrected the problem immediately. Nurses have taken out similar sounding drugs (ace inhibitors)from the accudose machines but called pharmacy when what they've chosen does not match the eMAR to prevent errors.

I ask all my adjunct clinical faculty to subscribe, read, and put into practice what they learn from this newsletter.

see answer above

with implementation of barcode med administration technology and collaborating with pharmacy re: any med error and strategies to prevent similar errors in the future

Nursing collaborates with the pharmacist (this pharmacist is from a different site). We do walks on the unit together to check refigerators, IVs, syringes, etc.

see above - we work very closely with Pharmacy.

Discussed with inpatient unit managers and they work with pharmacy to make changes.

I shared with the Pain Team the issue where PCA by Proxy is not advisable.

Once again, managment...however, the nurse manager does also receive the newsletter.

This newsletter is now shared monthly with all our facility supervisors, department heads and acute care managers. The information is then passed on to staff via photocopies and postings in the various departments, as well as circulated to all physicians.

forward to all nursing managers and post on all units

I am the nurse educator and I am always involved with procedures and policies to increase awareness and make our facility as safe as it can be

Promotes discussions with Pharmacy personnel to collaborate on ways to fix situations.

Working with satelitte pharmacy to isolate meds

Our facility developed Medication Management training at the unit level to help ensure safe practices, keep drug stock current, prevent look alike/sound alike storage, etc.

As above.

have used in our rooy cause analysis conducted on medciatio errors

Discussed above at Medical Staff and Pharmacy and Therapuetic Committee meetings

We have taken some information to our Medication Performance Improvement Team and have made safety recommendations

I have written policies that affect more than one department or unit.

Our nurse educator does this on a monthly basis

Have collaborated with our Pharmacy and Patient Safety/Risk Manager to implement some recommendations regarding safe medication practices

medication safety committee

Strong nursing representation on Medical Staff's P&T committee

Not yet

implemented comittee to look at all errors across peds and plan changes around error reduction

Discussion at practice meetings

Work with pharmacy personnel to continually reasses protective proactive stratagies.

When we review medication practices pharmacy is always involved. The newsletter is sent to ALL clinical departments not just nursing. Hospital staff can access current and past newlsetters via our hospital intraNet.

pharmacist audits monthly

adding allergies to computer before entering medication orders

developing ideas for labeling of medications

As Director of Quality, I will be doing this more often.

The newsletter is very helpful and used during our discussions at the hospital's medication administration team meeting.

Information is relayed to committees that are focused on specific issues, i.e. the pca pump information went to committee looking at the safety of our pumps.

We discuss the contents of the newsletter at our Nursing Pharmacy meetings, or in conversation with pharmacistis.

Discuss at P/T committee

abbeviations and conc eletrolytes

Consulting with our clinical pharmacist if ordered dosages seem out of normal range, or if drug ordered which I am not familiar regarding side-effects and administration routes/compatibilities.

On Med Use Committee and these are used to help us determine areas to look at for problems or potential problems

As above in 6a

The computerized medication system currently in use includes abbreviations that have been highlighted by JCAHO.

In the process of updating current medication policies.

management of home medications

Obtained funds from our hospital foundation to purchase medication error prevention posters and encouraging nursing administration to give med error prevention a higher profile in our hospital.

Tall Man Lettering with pharmacy

I sat on committees to improve medication safety.

as above

Increase Insulin safety

Recent newsletter was brought forward to Risk Management Team/Administrative Teams for review and update of diabetes medications policies and procedures.

Your newsletter is sent to me, via email, and I inturn print copies for distribution at the main pharmacy window. I also forward the email to all nurse managers and nurse directors for printing and posting within nursing units. In addition, we have a Pharmacy Nursing Liaison committee which meets monthly. The newsletter is also distributed at that meeting.

The Pharmacy shares their knowled of soun alike and look alike drugs.

Worked with pharmacy and risk management to develope policies and practices

In patient units (2) have included newsletter as a reference in orientation.

Education

See above

It was noted that acetone and sodium citrate were coming up dispensed into individual dose bottles that were the same size, shape, color and stored side by side in our medication cassette. Once this was pointed out, the packaging was changed.

Shared with our Quality and Practice council for nursing.

We have a safe order program that means all orders have to be written correctly, no unsafe abbrev., and reviewed before the order is put through to the patient

Medication committee member participation includes staff to disseminate information to all units.

I share the information with my other co-workers.

I use this newsletter as an adjunct to my section on Medication Errors in both first semester and second semester of LPN program. I have the students to select a newsletter and then write a short synopsis of one topic that is presented in that newsletter. The responses from the students are excellent. The learning gained is related to the actual events/content presented and learning related to using an internet source for reliable professional info.

The introduction of the medication reconciliation form

In process of revamping same sounding drugs. Nurses review the articles and provide input

We changed our checklist and scheduling practice with MRI and pt's wearing a medication patch.

We now have a medication safety officer that is a pharmacist. LA/SA drugs are separated on the units and colored flags identify these.

A binder is maintained on each nursing unit with monthly ISMP NurseAdvise-ERR

Used with Patient Safety Committee to increase awareness.

Work directly with pharmacy department to implement needed changes.

pharmacy has taken steps in guarding the hi alert drugs, especially IV Potassium

when there is any doubt, I will check with the pharmacist

worked with pharmacy to change policy and procedures

The information is shared with Patient Safety Council that includes nursing, pharmacy, radiology, respiratory care and lab. The information is sent via e-mail to the multi-disciplinary Council members and also made available to front line staff via e-mail as well as in hard copy. I have received positive feedback from readers as to the clarity and usefulness of the content. Thank you for making this newsletter avilable.

The newsletter information is part our monthly Nursing Performance & Patient Safety Council meetings. information is share with nursing leadership and staff.

The newsletter is distributed to our Interdisciplinary BarCode Medication Administration Team as well as to all nursing units. When I see an issue discussed in the newsletter that I believe could be a safety issue in our facility I add it to the agenda. We then examine our practice and determine if we need to institute changes.

my dog was going for a "procedure" 2 weeks ago, & i showed the vet tech the copy dealing with labeling meds on the operative field-i read about the horrible errors/resulting deaths of people when unlabeled things were used in error-i was horrified, as i am a former OP nurse, & to NOT label something is unforgivable... the vet techs assured me that all their meds were labeled..my boy came out ok, so i guess they were careful.THANK GOD.

When I perform risk reduction consultation visits I discuss points with pharmacists, nursing, and administrative leaders.

Ob related drug if warnings are indicated, we work with pharmacy to develop safety measures.

as above we share our info. we all the diciplines

The head of the pharmacy dept sends the newsletter to nursing dept managers and other depts.

Used on an OBQI team

see above

see above

Use the information to validate important changes in the system

I forward the info to our Pharmacy which I am sure utilizes it.

As per above

Discuss with pharmacist often about errors

Work closely with our pharmacists to implement med errors: As a new employee, identified need for a pyxis, with med cart implemented immediately. Developed system with pharmacy and nursing to check expiration dates, to prevent expired drugs to be removed from stock. Separate look alike/sound alike meds! NO more abbreviations permitted from physicians. MD orders have a list of unapproved and unacceptable JCAHO med abbreviations on the right side of the doctors orders to REMIND our docs to NOT use those abbreviations that have been used in the past and associated with high incidence of med errors! Remind staff to use RB "readback" on the telephone orders. Discourage physicians from use of verbal orders! Encourage our physician to prepare their standing orders TYPED with clear documentation of admitting orders, to avoid med errors.

As above - sharing the info with other disciplines, other units

Have done in previous place of employment via bi-monthly review of med. errors with the Pharmacist.

removal KCL from unit, insulin and heparin double checks

I double check with pharmacy if I have questions.

Instructed our nurses to consult the pt's pharmacist more often for any questions at all.

Not yet

Pharmacy notifies us of what new protocol they'll be putting in place.

Improve patient communication

much more pharm presence in clinical areas, library helps order current nsgdrug refences we like to use, pharm helped make new code book drug charts

Medication Process Group responsible for making change to computerized paper MAR has nursing, pharmacy, IT, QI representation and these newsletters are provided at each mtg

College of Medicine with medical students

Worked with Pharmacy..for changing look alike med packaging..on committee for med safety..implemented double check for high risk meds (narcs, Heparin, Insulin)

Information is distributed to all departments and discussed during quarterly meeting with Pain Champions.

Through PI

Made suggestions around Tall Man lettering for similar drug names to pharmacy.

PRN effectivness

Newsletter information shared with Medical Center Medication Management Committee and Performance Improvement peers.

L.B. V. A. is full of people of all countries and I like it. Is like bee in a global team

Some issues have been taken to our medication safety committee

as above

will share informations with colleagues to enhance their safety alert with medications.

collaborated with another nurse about the discrepancies on the preprinted epidural order to the preprinted MAR for epidural.

Collaborated with pharmacy to improve labeling, separate look alike drugs and woked with team to improve patient identification with a scannable ID band

As above.

Overriding a med in the pyxis requires another nurse to co-sign.

new insulin order form

I am a part of the team that looks at prohibited abbreviations and other medication safety measures.

We have a listing of sound alike drugs on the unit.

e-mar

I teach nurses and share this information with them

all staff required to review

Medication Tracers and documentation of PRN effectiveness.

See statement under number 6

The topic of labeling syringes on the sterile field in the ED where I work was discussed at the last ED staff meeting.

pharmacy also reviews it and as been involved in changes as noted-

I call when necessary

overnight unit

If I find two consecutives, I contact the pharmacy manager though the e-mail or telephone to correct them and get discussed to prevent further prevention or strengthen the weaken the process to corect not to pick on any body.

Code Blue Committee devised an appropriate guideline for Peds patient's med. administration when the patient is admitted

We recently had a discussion about the Elastomeric pump sizes and their uses.

Comunication with all the nursing staff for the Emergency Department regarding medication safety. Back to basics: The 5 "R's".

as noted above

it is good practice

not yet

also share with other institution establishing continuity of practice guidelines

Will review newsletters with consultant pharmacist

changed charting to reflect no trailing zeros, writing out values and not using abbreviations. We do have standard order sheets for labor and delivery that are typed and less change for transcription medication errors. Avoid common abbreviation MgSO4 and MSO4

Labeling medications on "the field" Medication reconciliation

2 check unfamiliar doses (i.e. for children) and the pharmacist

Development of pre-printed procedure order

see above

I used the PCA pump issues to help design an education program as well as design and action plan for PI

Working on pharmacy committee

reinforce to MD performing procedure

JCAHO task force is multidisciplinary - we use information as exsamples on how to provide a safer medical practice

7. The topics covered in the newsletter that I found most useful were:

types of errors, I use as examples during lectures to new nurses

Examples of medications in real situations

Sources and frequency of medication errors.

Examples of problems/situations others have had.

did you know, check it out, nice catch, pearls for pts, and safety wire - brief catchy items

All are very informative

Examples of real errors

Any maternal child health inforamtion or 'general' medication safety tips. I print a twice a month newsletter for my staff and I always include a 'tip' from your newsletter

Variety

Labeling all solutions and drugs, methemoglobinemia and many others.

what other facilities do

Med errors that have occurred at other facilities. They are excellent learning tools.

The entire newsletter is useful!

PCA, WRITTEN ORDER ERRORS, MISUNDERSTOOOD INSULIN ORERS, MEDICATIONS IN VIALS THAT LOOK THE SAME, MEDICATIONS THAT SOUND OR THE SPELLING IS SIMILAR

Examples of the errors and the recommendations to avoid future errors.

All very helpful especially with the mediation reconciliation initiative we are embarking upon

CHECK IT OUT TIDBITS

labeling, patient identification

All are useful at different times.

Meds commonly used in our organization, anecdotes from practice.

The "near miss" or actual events that could have been prevented - I do risk and quality nursing

Insulin safety. High alert meds.Dangerous labeling.

Actual examples of what is happening out there.

Insulin examples

ways to prevent errors, common errors and how they occur, equipment issues that create problems

PCA pump isses were especially helpful in educating and alerting bedside caregivers to safety hazards.

Real life experiences and outcomes

ALL

Topics related to the National Patient Safety Standards.

error prevention, legible handwriting

Two part series on PCA pumps

discussions that address human factors and that address systems issues

all of 'em!

articles related to potential errors and solutions to correct

Dosage confusion with written Rx's.

Those comments related to ambulatory care.

actual copies of orders that were interpreted incorrectly

Making me aware of medication name similarities.

Check it Out!

Examples of errors from other institutions, and suggestions for improvement of practice stemming from the errors

All

Everything overall seems useful.

DRUG INFORMATION

Practice issues

Examples and stories of mistakes and near misses

Most all the topics are relevant. Those concerning Joint Commission's NPSGs.

They are all pertinent - though I do particularly like the featured article.

prevention measures

Sharing of errors and issues along with actions taken to prevent.

Instead of a specific topic, I find the stories of errors that have occcurred in various areas useful.

PCA by proxy, but all are good. Like the mini case reviews that support the topic of discussion

Medication error examples and updates

I don't necessarily remember ones in particular. I have found many to be useful.

Handwriting issues

Any risk reduction discussions

I have found all of the topics to be useful.

I am a new subscriber and have only read about 4 copies

Medication safety

"Check it Out"

ALl the info is useful

Actual mistakes. We learn from those mistakes.

Insulin and diabetes medication, look alike/sound alike drugs.

PCA alerts. I find that I generally read the newsletter beginning to end and find the information useful and relevant.

Reconciliation and legibility

issues related to handwriting & clarification of orders

Everything. I print out the newsletter each month, and provide it to all nursing and respiratory staff in the clinical departments. They receive educational credit for reading it.

Information about errors that have actually occurred are good springboards for discussion....could that ever happen here?.....how can we prevent it?

Error prone drugs. Safety suggestions

7

test

Real-life stories about mistakes made by health care professionals.

look a like and sound a likes. Real life stories can say more than a one page of research.

Prevention of medication error techniques

ALL

Actually most all the articles have been interesting reading. I always print it out and encourage my staff to read it.

High Alert Medication Information

Mix up in drugs. All pediatric stuff.

It is helpful to hear examples of errors. It makes more of an impact and is a practical application.

"Check it out" about "look alike"; "sound alike" drugs. Real examples of medication errors that were shared

All topics with examples of how error was made and what has been done to correct the problem

All of the information is useful

Safety wires, In the Spotlight, and the main articles

Errors or near misses

Safety notes for unreadable labels

Medication errors due to lack of labeling.

Examples of hand-written orders and how they lead to confusion, and problems presented by drug manufacturers using similarly sounding/spelled names and strengths of medications.

some of the saves that were done by staff and how they recognized the possible error

some topics are very specific to spedialized practice settings others have a broader appeal but all have excellent information and can translate from one setting to the next in difficult to measure ways.

i am glad you asked! in either the june or july issue this year there was an article about a med error that was made due to illegible handwriting. the drug was supposed to be avandia, but poorly written looked like coumadin. the only clue was the dose: 9 mg. which could possibly (but not likely) have been a coumadin dose. i copied and enlarged the handwriting sample as it appeared in tha article ans used on my education board..which coincidentally was "medication safety"right after our jcaho survey. the most powerful example of patient safety concerns i have ever seen ..after 33 years of nursing!

errors reported in other hospitals that we could learn from, the artciles are clear and to the point

use of PCA. Abrevations,real life examples of errors

Sound alike drugs-Unacceptable abbreviations-Handwriting atrocities- incompatability issues.

I like the actual use of a "Do-Not-Use" Abbreviation. We publish them in our hospital newsletter and Physicain's Newsletter. Very helpful. All the articles are wonderful. This publication is very valuable to our nursing staff. It is one of the most read newsletter in the nursing department!! And that beats our gossip sheet.

All of it.

All interesting, Like the info on Hydro morph

I read each and every article in every newsletter!!

check it out section

Examples of frequents medication errors & tips to prevent errors.

All of them!

Medication errors that have been made by others and ways they could have been prevented and look alike drugs.

PCA, meds etc

Several med-surg and obstetric drugs & potential areas for error as there are risks of litigation

Scenerios/examples where errors occur.

Those relevant to the outpatient practice. We frequently use some senarios to educate physicians as well as staff.

Validated for nurses why we need to double check before passing medications.

Near misses---if they can almost happen we can be more proactive

I find them all very helpful

IV fluids administered to trach cuffs PCA Pump recommendations

All

Intravenous pumps and insulin errors

a review of errors or near misses

PCA by Proxy

sound alike medications

PCA mistakes

potential med errors and methods to avoid

Medication practices / Check it out section

I like the real examples of medication errors. I use them in my teaching.

Examples of how medication errors occur. Most nurses can relate to the situations described.

adverse reactions

All of it was very interesting and helpful.

The main articles and check it out

all

updates on procedures

Acetaminophen, Pyxis. Acutally, almost all of them have been useful.

med errors and machine failures

all especially peds

error prevention for drug mix ups.

I find the case studies helpful, links to other resources, recommendations and how to implement current trends in medication safety initiatives.

Cautions regarding potentials for error.

Each issue has something useful I can discuss with the students!

All useful for informtion

The dumb and not so obviously dumb errors others make. Also examples of handwriting that was toooooo easy to misunderstand.

i like the specific and real examples of things that happened in practice... it is very easy to relate to

psychotropic medications

Learning from other's mistakes. What is most poinant is what has already happened.

Suggestions for preventing errors.

most are useful

Error prevention and electronic dispensing of medication.

Common medication errors , new legislation and clinical practice isssues

Drug label

medication alerts

The lastest imformation about specific drugs and the areas where nurses fall short in understanding and application.

examples of errors and how to avoid the errors

abbreviation list

Anything to do with patient safety and JCAHO guidelines.

Actual examples of error instances - makes correlation to practice much easier

the examples of the many errors and statitics

general error prevention

I cannot give you specific topics, but your use of cases to demonstrate errors has been very helpful in sharing info with staff nurses.

high risk medications

"Check it Out" or clinical pearls

Sharing of examples of errors from other facilities. The staff do not think that some of these things would happen until you hear how easily it does.

Current Aug 2005 issue

I think all the topics I find useful in one way or another.

the look alike and sound alike information and warnings

Infusion issues

all of them

Since I am part of the Saftey team at my hospital I find all the information useful, but the topics that affect nursing are most helpful.

psychiatry references

All articles on Hospice, medication updates

transcribing errors, automated pharmacy errors

Safety w/ PCA pumps

flammability importance of labelling and reading labels...good reminder!

Examples of medication errors and ways to prevent them. Would like to see more Behavioral Health Examples though (pertinent to my organization)

specific examples of current problems and what the institution did to try to stop it from happening again

PCA

Most have some useful information whether the problem exits in our facility or not.

The main articles and the 'check it out'

The main articles and the 'check it out'

I love the stories - it shows that it really happens and can be a problem

Identification on look alikes/sound alikes

The "nice catch" items are always interesting and pertinent

PCA's, abbreviations, and sound alike medications

Sound-a-like names, similar labeling, etc...

labels , watching out for drugs that could look alot alike

The real life scenarios. This allows the nursing students awareness of errors in clinical practice

Look alike drugs. Learning from the "near misses" and med errors described.

Product label risks. Actual error reporting. Legibility examples.

Issues related to pain management

anything related to physician office practice

Everything

labeling of medications on steril fields

All topics are useful. We all can use some reminders and improve our practice

case historyies

Proper abbreviations.

All very useful.Common administraion and prescibing errors. Misconceptions about error reporting

items related to med misuse among the elderly; monitoring of side effects of high-utilization medications

Medication errors as reported by health care workers make me more aware

How human error can affect a change in the way we practice and teach.

PCA info, increased awareness of how common medication errors can occur

Real life examples of errors which had occured.

New letter up dates were most helpful to me and those in the patient Safety Division.

Ones that I could convert to Home Health Practice

All topics

Legiability

Visual examples of illegibility leading to errors visual examples of look-alike drug packaging and sound alike drugs Survey result compilations from other organizations Visual examples of errors connecting O2 and BP tubes to IV lines

written examples of medication errors

main topic and check it out always helpful

mislabeled or unlabeled meds

Respiratory Drugs

I like the pieces about med errors.

Every month I here the nursing staff in one form or another talking about "something" in this newsletter. It is a matter of personal preference who finds what most useful. It is a very good newsletter, one that I feel is read the most by nursing staff.

alerts on drugs and IV pumps

I find the actual case scenarios and drug recalls most helpful. The case scenarios show what can happen and what can be done to avoid the occurence.

How close medication labels or packaging were, that could cause an error.

Safety, side effects, new drugs,

Patient safety/med error prevention tips

Practical tips for bedside nurses to prevent medication errors; review of events at other facilities that offer a "heads up" to our nurses. What practices are at other facilities that we can offer as support to our nurses who may object to an aspect of a protocol.

all

Real-life examples of errors. This gives more credence to me as a supervisor when I'm trying to convey the importance of pt. safety.

SAFETY ISSUE

Reading about products that appear identical based on the initial labelling.

Home Care applicability

All

The examples and discussion that it brings to the staff and the improvement in thinking about the deliver of care.

the labeling of the drugs in the OR but we have extended this to the ICU's

Use of abbreviations and overbearing physicians

Medcation Errors Sound alike meds

the topic in regards to PCA pumps we were in the process of purchasing new pumps when that article came out and we used your guidelines in evaluating the PCAs.

Real life examples of how errors occur

PCA's and intimidation

misleading names, differing doses for different combination drugs

Suggestions on labeling protocol.

Check it out column

near misses, sentinel events

label,label,label!!!!!!!

medications related to medical-surgical nursing

Topics that offered an overview as to the global problems with medication errors

Floor Nursing Issues

Labeling of products, especially flAMMABLE ONES

drug mixups

New drug warnings

error prevention and examples

All of them.

Problems drug administration has caused for other nurses and a remedy.

Med safety, process improvement

all topics are interesting to read in the letter

All of them!

Those in "Safety Wires"

Medication error examples, I makes more of an impact with the staff when they read about some of the outcomes to medication errors. And legability of orders.

How errors can occur and methods to avoid future errors. I read the entire newsletter.

all

I think they are all useful! I can't think of anything that stands out in my mind.

examples with outcomes

Examples of actual errors

THe real-time stories - adds the Patient Perspective to the tak driven healthcare world.

Tips for Collaboration; teamwork focuses for patient safety

medication and device safety issues

Flamable products; stories about what has happened to other practitioners and patients

Actual errors or near misses that actually occured

Flammable items.

applications to ambulatory care

all

all topics have been found to be useful, sometimes the information is already known but it serves as re enforcement.

All

documentation

not 1 inparticular

I really find the clinical scenarios helpful when teaching students.

drug interactions, wrong dosage and new formulations of old "familiar" drugs

Medication error, article on MDI's

High risk medications, and infomration outlined above

the articles themselves

need more for long term care but all is useful

cardiac meds as i work in icu/ccu

All are valuable

Mistakes that have made

all medication administration and error prevention--stats are great!

Actual cases that happened

all; excellent short, educational resource

situation examples

All

I love them all.

All is helpful

Check It Out

I found the news letter to be very informative & I looked forwarded to getting it. I distributed the news letter to all the nurses in my facility.

All topics very useful THANK YOU!

real case examples

examples of errors highlight self reflection

Varied

medication problem areas addressed and overall nsg info

Poorly written doctor's orders re-printed are a great teaching tool!

Please keep these coming!

Rule of 6 and Broselow tape issues

"Check it out" tips. You always address the "hot" topics current issues.

Insulins

We love them all.

The type of errors that are usually made ann side affects of specific drugs

Alerts for confusing drug names, labeling, and new drugs

Labeling of each medication, ( syringes with medications)

Like to learn from example. To know how others made simple mistakes draws attention to how easy it is to make the mistake and helps to keepfrom making the same mistake in my practice.

Medication errors.

Error discussions and how they occured.

pt education re PCA

Flammability Labeling

EXAMPLES OF PROBLEMS FOUND

medications

labeling medications on the sterile field

OR practices

all are helpful

Everything!! There isn't any section, story, information, etc. that is not interesting or useful for daily practice. Patient safety cannot be overpracticed.

Examples of how errors occurred.

NEW DRUGS. SPECIAL WARNINGS

Actual scenarios where medication errors ahve occured so I could use them for teaching.

The newsletter has so many practical and applicable topics, I cannot not say one if more useful than another.

PCA,free flow protection-smart pumps,bar coding

All topics presented are very useful. I enjoy wtih newsletter.

Medication safety

Specific Med Errors & Suggestions for Correction

med errors, documentation

They are all useful

look closer at the labels, even if I have to get a magifing glass to read the print

Anything related to radiology practice and pre-admission testing

The tips in the Check it Out column.

meds-sound alike/look alike, how errors occurred within a system

Revisiting old topics are always helpful and stories make it easy to remember.

good reminder about caution with flammable products

all

Most issues very relevant info

Stories relating to drug errors.

All

importance of all containers to be labeled

Every issue is useful. I would not know where to start.

all

PCA

Board of nursing stance on drug errors.

The day to day real life examples of what could happen.

Examining the copies of RX's that were misinterpreted. Helps keep me on my toes! However, the CME is the most useful for me. Generally, prescribing safety & being able to learn from others mistakes!

Everthing related to medication.

Examples of incidents and sugested measures to increase safety

1. review safety requirements 2. the actual cases of errors reported 3. suggestions to make work areas saferand increase awareness

I like the scenarios...real world stuff.

I am totally unaware of this newsletter. It sounds like an excellent newsletter.

medication safety

All

Actual incidents where not following the five (or seven rights) of med adminstration resulted in an error. These stories impress to nurses that sloppy practice really can harm patients.

highlights of unsafe situations....chances are if someone else is having a problem with a medication I use, I could potentially be having the same one

The suggestions for sterile labeling in the OR and Labor and del, and ER, I have found to be very helpful and hope to incorperate them into everyday practice

Individual examples are helpful.

Most all topics apply in some sort of way since Med/Surg Critical Care area.

Specific Suggestions regarding look-alike drugs

I like the check it out section, but find all of the information is valuable.

All - especially personal anecdotal accounts of errors

Various

the issues that happen that you would think could NEVER happen such as hooking a tube feeding up to a central line or mixing up the IV tubing and the BP cuff tubing.

pertinent to labor/delivery patients

I always find the check it out portion of the newsletter informative

Everything

look alikes name alikes

medication similarities

Look alikes, PCA, Connecting infusion to alternate routes ie a trach cuff.

Errors made.

Medicatioon labeling

medication allerts

Everything is useful

I like the fomate, it is easy to read and highlights important issues.

all of them

all were pertinent and useful

Issues relating to ambulatory & physician office patients.

insulin therapies, positive identification, Baxter Clearlink

Everything

medications used in the physical rehabilitation setting

Abb reviations,Insulin articles,all of them were useful

patient as well as drug identification in order to prevent errors

Those related to patients with gastrointestinal diseases and wounds

All, keep up the great job. You provide a varity of information that covers all areas in nursing.

The article on the large water bags used inadvertenly for IV's, and the articles on methergine.

High Alert Medications, Medication labeling, Abbreviation problems

all

EVERYTHING!!

Medication errors

those dealing with critical care issues

all information that has been covered has been very interesting- I find the "near miss" events the most useful

Examples of med errors made

Perioperative information

Found very little not useful

I find most articles useful - perhaps not today - but often I will think "I read something like that in the ISMP newsletter" when I find a problem.

PCA, High alert medications

Community related

all topics are interesting and make me stop and think how to apply them in our ASC

medication name confusion issues, wrong dose info

medication incidents and anything ambulatory

check it out

PCA information

those related to obstetrics and operative

examples of unclear med orders

Real life examples of errors that have occurred in all depts (ED and ambulatory)

All are great. Liked Check it out section

they are all interesting and useful

Everything

Examples of errors.

check it out is brief and to the point.

Alerts with patient events-any eye opener. Check it out.

Tips to prevent med errors.

Medications utilized in ICU,ED, PACU, OR

Safety issues with PCA

Scenarios that show how easily mistakes can be made.

Free CEU program.

pertaining to IV therapy

behavior health med issues

Would LIKE to see topic of MEDICATION RECONCILIATION (JCAHO rec) addressed!

Real-life examples of patients who were harmed by a med error.

stories of errors

errors with Pyxis machines in use

fentanyl patch issues (8-11-05)

?

ALL were useful!

real life stories, solutions that were created because of these errors

Look alike medication

Similar name/labeling problem issues.

Examples from various practice settings

Documentation errors are useful for my class

Identification errors

PCA pumps root cause analysis, Magnesium sulfate med errors, brethine med alert, and the case scenarios are great!

Unable to say

practice info

Related to medication safety.

the dangers of flammability of preparation materials in conjunction w/ cauterization

Topics covering philosophy and practise. We are a mental health unit without much medical technology.

Issues regarding insulin, unclear written orders, ways to make change in an institution.

All

I find the safety wires a avery imfoprmative column.

PCA incidents, mislabelling of meds (my pet peeve).

Real-life examples and outcomes of medication errors.

Look-alike products; flammability

examples, outcomes and practice changes

Flammable products; the "check it out" section

All the topics are useful for practicing nurses

All are helpful.

Helpful Hints/tips

medication error alerts in the clinical setting

All good

Professional Accountability and responsibility in givine medications.

Professional Accountability and responsibility in givine medications.

All articles related to patient safety.

items that pertain to outpatient, primarry care medicine

Events that happen in hosptials. We rally had a lot of discussion about your articles on intimidation. That was very timely!

NA

IMPORTANCE OF LABELING

Examples of errors that occured so that we could read them and then apply to other similar areas

flammable products and poor labeling

Examples of the tragedies when we don't label meds.

PCA and enteral feeding issues great.

All topics.

In the August 2005 issue the medication error topics were most useful.

Out patient items

Look alike/sound alike--tall man lettering; case scenarios

disasters

fire in the or

case studies

the check it out section. we are all very busy professionals and the cut to the chase is most appreciated

Medication safety

Issues related to sound alike look alike meds; case studies of actual incidents that happen

Examples of errors from actual practice

Examples of errors being made elsewhere and learning from their errors.

All medication err information.

Examples really hit home

Actual Root Cause Analysis Proactive tips for practice.

flammability of certain products; also how clorhexidine could be mistaken for contrast media. I have worked where clorhexidine was used all the time in labor & delivery by pouring it into an unlabeled basin on the sterile field. I hope this changes after reading your safety newsletter.

flammable products adn the teleconference

Specific examples of errors and how they were made; confusing labeling on medication vials or bottles.

LABELING INFORMATION TO BE AWARE OF IN MEDICATIONS.

examples of real errors that impact people - my staff responds to this better than some thedoretical error that may happen.

Medication error prevention

Examples and stories

Confused drug names, high-alert medications, and error-prone abbreviations, symbols and dose designations.

I read it all!!!

Same-name dangers; examples of confusing written prescriptions; dosage errors

errors that potentially may occur

Like the examples of med erros and espacially those relating to poor penmanship or other "sloppy" methods used in current reality

med error events

everything

illegible handwriting, questioning of physician orders

examples of errors

I find the whole thing useful!!!

Look alike, sound alike.

Any practice related issues that were broad enough to be important in any practice setting.

anything on medication errors

Issues/concerns around devices.

cultural issues related to medications. This was very time-appropriate as we had just had an inservice regarding cultural competency.

new recommendations regarding how to write medication orders in order to prevent errors

Those related to PCA

the actual medication errors or close calls that the article references. The cultural articale was very good.

I have learned something from every newsletter. I find it especially useful for changes in the future. I find it useful for articles outside of my expertise. At least I can stay abreast of current topics other nurses are discussing.

I loved the diversity discussion on how meidcations are metabolized differently and how to present this to the different patient populations. Discussion of experiences with medications errors and how they were handled. New medications that are named similar to older medications.

N/A

medication info

look alike products,minimize calculations,unit dosing

all

medication issues

All

Devices connecting to needleless IV ports. The articles on the PCA pumps and drug administration.

The incidents or near misses that have occured in other hospitals

Same drug mix up How not to write decimels in orders.

All is not what it seems is extremely helpful.

medication management and near miss information

steps to avoid errors--READ THE LABEL

TYPES OF ERRORS MADE AND HOW THEY CAN BE AVOIDED

JCAHO universal protocol

specific errors

misintepreted medications

EXAMPLES of med errors!

transcritpion and dose errors.

Subject dependent. I work in ED so that is my focus.

Examples if misinterpreted handwritten prescriptions, and how they were discovered/near misses avoided. Education used to prevent errors from recurring.

PCA -epidurals was the most helpful, informative of all the newsletters.

everything is useful in one way or the other. :)

I liked the info re: insulin and heparin syringes and sent that to a nursing home for which I previously worked.

all of the real life examples are most helpful and useful...especially those copies of actual handwritten examples that caused error

All of them except surgery because we do not have a surgery unit. However, it is interesting

Examples of errors that have occurred including pictures of handwriting, actual vials, etc.

Individual errors that have occurred and how they occurred - this is helpfull in evaluating our systems.

I have used the PCA topic extensively in educating new nurses regarding safety. We pass out the news letter at orientation of new nurses.

Near misses. they help to keep me vigilent

I find the entire newsletter incredibly helpful in teaching students about medication errors.

I read the whole newsletter. I find all information useful. For drugs not related to my current area of practice, the information is still useful because I get to know the issues related to those meds ie psygh meds

all

i like them all

How technology can be helpful, but also has to be used properly.

I believe the most powerful tools presented in the newsletter are the actual examples of occurences from facilities across the country that make us identify with practices that we are very familiar with from our own experiences.

Look alike and sound alike medications..."Near-misses"

none

information about specific incidents that happened

medication safety

prevention of med errors

anything on medication safety. especially look alike and sound alike awareness. Legibility of orders and intrepretation of them

Examples of real-life medications ordered by providers, with the explanation of what they actually were ordering.

Discussions of actual errors.

Medication errors due to use of abbreviations, poor hand writting and misinterpretation of the written orders. Also the possiblity of severe errors by having BP machines have connections which can be accidentily attached to oxygen lines.

everything is helpful

All

Alerts--those things that impact safety

drug intereatcions; information about medication errors

Anything related to errors and ways to change or store a medication

PCA, legibility issues, medication mixups, case studies

none

insulin, technology errors like pumps

stories about errors

Actual examples...situations.

Handwriting examples, Check it out & safety wires sections.

like drugs, the new 2006 Pt Safety from JCAHO

look alike sound alike

There have been several great topics in these issues!

Safety wires.

All is not as it seems Q&A

Case studies and prevention strategies

Medication errors and ways to prevent them. PCA pumps.

ALL

all are useful

Error prevention related information such as drugs with similar names, problems associated with handwriting

We have only seen a few copies but I believe the article this month related to cultural diversity is especially helpful.

Those regarding PCAs, the automatic medication dispensing (Pyxis), and especially the article regarding propofol and lipid error.

Actual examples of errors caught. Near miss strategies.

PCA pumps High reliability organizatiosn

medication safety and ways to decrease errors.

Equipment problems. Meds are covered by many sources but I can not always find equipment related information.

Reality based examples and consequences.

Medication error prevention strategies.

PCA; cultural impacts

Illegible handwritten orders misinterpreted. The need for safety control features on technological tools, e.g., IV pumps, PYXIS carts, etc.

the handwritten errors....the 2 part PCA topic...

all very helpful in someway.

all

PCA series and the human factor relationship with errors and error potential

Practical examples of errors and outcomes of errors as well as the suggestions for strategies to prevent errors

Every topic is useful. Since we have just begun including an addendum to all evaluations at the hospital highlighting trans-cultural awareness, the September article on cultural diversity was particularly relevant.

irrelevant to my practice

usually most of it is helpful

Thw actual experiences of others and ways to improve.

Real life examples

All the topics have been timely. The fact that it is focused and easy to read is helpful.

All are useful

medications reactions and medications with similiar spellings and errors and prevention of errors

Alerts with look alike meds. Examples of error from intial order writing to med administration

allergic reactions, sound alikes, jacho news, incidents to look out for that could occur.

examples that the staff could visualize-

When you show how med errors have been made--using the examples

Individual examples of errors that can be used for case studies

Medication labeling, frequently reported errors.

Drug name similarities/similar labels problems.

Risk management strategies for nurses

Preventing med errors and patient injury

Written examples of errors which helped me show new staff how poor sloppy had writing can be dangerous.Staff must be more careful in writen communication

medication errors

Similar looking meds

Verbal orders and the current meds and diversity.

I think that most of the articles published are thought provoking. There are times when I read this and say to myself, why didn't I think of that.

I love them all....

Medication reconciliation

I have only seen two issues so it is difficult to say. Real life situations are always helpful and information sites.

they all seem pertinent and timely.

all topics are interesting- I especially appreciate the format, short informative pieces w/concrete examples that hit home

specific meds listed suggestions on compliance in regards to safety and medication administration

enteral feeding interactions

Insulin administration prevention of mistaking one kind for another.

those related to national patient safety goals

Any that are applicable across practice settings

The medication update, alerts and practical tips that help healthcare professional improve safe medication practice and improve patientoucome.

it is short enough to read quickly, & i find every piece of info that could help avert a catastrophe useful

N/A

look alike vials for injection

System errors and need for tracking to make safer practise environments

legibility

all of them

the various topics

Avoiding medication errors

all

etnic tendencies

etnic tendencies

Drug interactions,Cultural awareness-very important in provide the best care for people of all races

About mistaking one drug for another

The JCAHO NPSG that are being reviewed in your newsletters, such as medication safety issues!!! Very good!

Positive Identification of solutions---I think it is a good reminder to be prudent in labeling solutions and syringes to ensure safety

Issues relating to home health care

The common error. Just a reminder of double checking everything and clarifying.

it was all interesting

The medication administration information

flamable sprays

look a likes

Actual errors that have occured and how it could have been prevented.

Protonix errors

Most commonly prescribed drugs Cultural diversity and medication safety

unacceptable abbreviations, all the info on PCA. Case study exampes really bring the message home.

Dangerous abreviations

case studies & examples

Stories that describe what a practitioner was doing and what happened unexpectedly as a result of less than sufficient info.

med errors / discrepancies in doctors orders

I find any information provided regarding med error/inappropriate administration of meds extremely useful (NG drugs given IV, blood pressure tubing that could be hooked up to other tubing) and pertinent to front-line practice. I use info from the newsletter in just about every one of my monthly newsletters or posters

Related to Home Health

Many were useful

ABOUT HERBAL MEDS.

Real life incidents

i find reading the errors made really makes me think when i administer meds

ED trends related medication errors

Your concept that the drug companies have too much liberty in design of packaging, naming and labeling of meds. It promotes a "safety awareness" in the RN that goes beyond the narrow opinion of the error being the fault of the local pharmacy, or nurse giving the med. It also promotes a "patient advocate" attitude toward safer labeling and naming of meds., and that perhaps we do have a say in the matter.

Medication errors in relationship to the pediatric population.

examples of real errors. really I devour it all

I found so many topics useful and interesting. Sound alike/look alike drugs and how nurses accidentally gave wrong medications. How abbreviations can cause a real problem. I feel that if hospitals have computer documentation and ordering that the physician should place their medication orders directly into the computer to pharmacy, that way, one step is removed where mistakes are made during transcription of the physician's hand written order by nursing to pharmacy. With technology the way it is today, hospitals and physicians should not have a choice in doing this. Our system requires nurses to type in their nursing H&P's and Nursing Notes during their shift. M.D.s should document their H&P's and Progress Notes the same way as well as ordering directly in typed form to pharmacy. I feel a lot of mistakes can be avoided this way. Possibly having some kind of monetary reward to Physicians and Hospitals by insurance companies and Medicare and Medicaid that implement this type of system. Since Medication errors are the most common cause of errors and deaths in hospitals. To me this makes sense.

All

Actual examples of problems

types of errors, error examples, approved abbreviations vs. banned abbreviations

safety and prevention

med errors....solutions or ideas on how to prevent the same errors from happening in my facility

Prevention of errors

PCA by proxy, safety literature and cultural beliefs

Medication safety

I appreciate the alerts and examples of how poor handwriting, unclear labeling, (systems)etc can be changed to improve patient safety.

How errors may be difficult to recognize.

I have not heard of this newsletter!

Stories of errors/near miss and what changes have been made to prevent them. In general all the information is useful in creating awareness.

Preventing medication errors

Cultural diversity and medication safety

yes,very usefull

unfortunately I have not read the newsletter but was told to complete the survey.

They have all been useful

situational examples.

Examples of errors and near misses and suggestions for avoiding errors.

Dosage error articles.

errors and their stories for the bedside nurse

Information about Ethyl chloride. Any problem with using it before wart removal by laser?

Review of cases we can used these as learning tools for our staff.

How NPH insulin can change appearance (Clear from cloudy) when contaminated by heparin

I like the articles that deal with diversity.

Each topic is interesting.

most topics were useful

pt to questions from the doctor,pharmacist or nurse about their medicines.

Reading about the beliefs of different cultures about medication compliance.

All topic are important, even labeling the solutions.The no blame approach is most important, team effort and system improvement will help to more errors being reported

saftey wires,all is not as it seems

Common errors of misinterpetations

Reviews on medication errors

History of cases that were performed where medication errors occurred and check it out section.

All topics, information in the newsletter were useful, meaning they could be used. However, this is dependent on what would work with your facility's current patient care delivery system.

Mix up of drugs and why: labels etc.

need to read more

Commom mistakes

I find the variety and the examples of actual errors are most helpful.

Handwriting samples

Case histories regarding medication errors.

Causes of errors, Precautionary Measures, Examples of errors

like words

Gnerally, everything is good

I like them all

cultural differences

Liposomal antineoplastics, cultural responses to medical care.

did not received last month newsletter

just reinforcement of being safe, safe, always practice safe procedures

all

information on drugs

predication errors

the part about the flammables

Importance of labeling EVERYTHING!

examples of errors that occurred

peri-operative

Do Not Use abbreviation charts

Enjoy the examples of written orders, pictures

Checking identification twice, physician "double checks" when there is poor penmanship.

flammable products

THE REST OF THIS FAXED SURVEY WAS CUT OFF

all. Very good use of all space available

all topics help RN always be vigilant

Chweck-it-out(?) and the actual case studies.

The "Checking It Out" column

don't use anything not labeled!!!

found all of it very interesting

Check it out

8. The topics covered in the newsletter that I found least useful were:

none

NOTHING

n/a

none

All topics are very good.

None

N/A

It is all great content!

None - I read every word every month!

Automated systems--but this is only because my facility DOES NOT have one at this time--we are only a 25 bed facility.

Nothing, it is all helpful.

none

Independent double double checks. When I shared this with new RNs starting at our hosp., I saw some surprised looks. I like the "Check It Out" column. It is a great reinforcement and suggested practice tool.

None

N/A

Computer / bar code .... not a factor in my workplace.

none

Hospital based solutions. I work in home care.

the long articles

Anything to do with hospital concerns.

N/A

None

None

There is no way to access archived issues of your newsletter. Thus, if I download it to my computer because the file is large, I no longer have access at another computer. This is a major flaw in your website. Thus, I can't refer my students to past issues. Or at least, information how to locate past issues is not easily found on your website.

None

None

None at this time

None

I have saved every copy. I can't remember any that I didn't find something useful.

NA

n/a

I enjoy all.

All are relevant

I did not compare "least" useful. I view all the information as potentially helpful.

I work in a psych setting so the issues related to critical care are not that relevant

I really can't remember anything that I found to be irrelevant.

none noted

8

test

Its all good.

none. All fo them are useful

Anything to do with OB.

Medication alerts for potential errors as wehave often identified before your publication

Sometimes there is too much information. Print is too small. Makes it hard for nurses to read "at a glance" while staffing.

I did not find any topics that were not helpful.

Survey regarding perceived Board of Nursing action in the event of a med error

None

None

We all know that intimidation happens. Would be nice to include how some places are able to decrease it.

None

have not found anything to be "least useful".

none

everything is useful

I find value in the newsletter as it is. I would ask for more real life stories to drive home safety issues.

It is all good info to be aware of.

none enjoy and find very beneficial

none

infrequently used drugs

Involving errors in surgey and ICU units.

None

none

Can't think of any off the top of my head....

can't remember

topics not pertinent to my specific practice but you need to cover all areas

All is good!

nothing

can'tthink of any

n/a

I have found each newsletter useful.

those not relevant to my practice as an ED nurse.

None

The idea that in OR the open containers are not already labeled??!?!?!!!?

i find it all very helpful

None

none

none

don't work in area where many meds are given - still found specific situations very interesting.

none

specific meds that we do not use in all areas

At this point in time look alike sound alike meds have been pretty much dealt with.

None

None

None

Most interviews

none

n/a

Unsure

none

Can not think of any @ present

none

None really

I do not recall any information that was not useful.

Issues unrelated to my pain management practice

hospital issues but only because i don't work in a hospital. i still enjoy learning about these issues

Nothing

Issues involving poor handwriting - The issue can only be solved by using physician order-entry so you are band-aiding the issue by pointing out that medications can be mistaken for one another when the physician doesn't write clearly.

Not all clinical people use all medications and know all of their generic names. It is helpful, to include the actions of the medication.

Since I practice in the long term care setting, a fair amount of the information is not applicable.

???????????

nothing

State Board of Nursing inquisiton article was confusing to me

N/A

Surgical and Hospital based practices are good info but we need forhome based practice not included and we have to adapt if we can to our care enviornment

None

NA

Long discussions of errors related to drugs not on our formulary

Whole issue is helpful

IV pump info

It is all helpful.

None

n/a

I found everything useful.

None

Computer dispensing systems. There are many different types available

Not many.

none

NIL

IV drugs

None

none

N/A

none--all information useful

nothing it is all great

It was all great!!!!!!

Items relating to ICU

Zero founf unuseful.

Other departments like the OR, PACU, ER, Out-Patient

o.r> EXAMPLES

See number 7. Since all were useful, none were least!

you can glean something useful from every article

None.

None. I think it is better to be informed of problems in all areas of practice.

None

none

All useful

none

None!

none

N/A

I do not work in a hospital/high level medical needs situation. More interested in day to day medication administration

none

Some articles on unit dosing systems are not pertinent to us in homecare. Would like to see more on medication assessmnet and teaching, involving patient.

rarely is there anything that I don't find useful.

None

more

all useful

N/A

Operative/perioperative issues simply because we are a LTC facility.

None - keep up the good work.

Still