Index. Note: Page numbers of article titles are in boldface type. A Advocacy, for patient-centered care, 230 for safe nurse-patient assignments, 267

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1 Note: Page numbers of article titles are in boldface type. A Advocacy, for patient-centered care, 230 for safe nurse-patient assignments, 267 B Barcode systems, for blood products, for patient identification, b-blockade and reduction of perioperative cardiac events, Blood transfusion, errors in, cognitive, 180 lapse, , 184 Blood transfusion safety, ABO-incompatibile blood administration and, hemolytic transfusion reaction from, ABO-incompatible blood administration and, analysis of systems and human factors in, 182 case example of, CauseMapping in case example, from patient identification error, 184 barcode systems for positive patient ID, hospital initiatives for, armband barcode management, CareFusion transfusion verification, education module for, specimen collection verification, 187 staff engagement in, standardized barcode labeling for blood products, wireless electronic transfusion verification, lapse errors in administration, interruptions, 182, 184 patient identification, 181 pretransfusion verification of blood-patient match, 184 process, 180 process analysis for, 180 radiofrequency identification, 185 through technology and process analysis, C CareFusion transfusion verification (TV), adoption of, and compliance with, 188 staff engagement at onset, training for, 188 Cause-and-effect diagram(s), CauseMapping, 244, Ishikawa diagram, Cause-and-effect mapping, of critical events, Crit Care Nurs Clin N Am 22 (2010) doi: /s (10) ccnursing.theclinics.com /10/$ see front matter ª 2010 Elsevier Inc. All rights reserved.

2 284 CauseMapping, in ABO-incompatible blood transfusion case, CauseMapping process, analysis in, simple map in, split cause in, 247 example in infant heparin overdose, problem definition in, 246 problem-solving in, solutions in, Causes, categories of, 249 Communication, in coordination of care and for quality outcomes, 259 in interdisciplinary collaborative planning and monitoring, 221 in patient-centered care, 230 interdisciplinary, in off-site perinatal care, Confusion Assessment Method for the ICU, assessment of delirium, Critical events, analysis of, as process, 244 as tool, basic parts in, 245 Ishikawa diagram, cause-and-effect, process maps in, 245 root cause analysis of, cause-and-effect mapping of, error analysis in, barriers to, 244 systems thinking and, at microsystem process level, 244 D Dexmedetonmidine, adverse effects of, 174 for mechanically ventilated patients, 174 E Emergency department (ED), building team relationships to improve safety, Enteral nutrition, areas of concern and recommendations, formula contamination, labeling, 199, 201 medication administration through feeding tube, misconnections in, 201 ordering, tube placement, 199, 202 aspiration pneumonia and, prevention of, 204 diarrhea and, assessment of, 204 guidelines for, 198 indications and use of, for adult patients, 198 in pediatric ICU, 198 monitoring for GI function and tolerance, 203 practice recommendations for, safe practices for, safety campaign, A.L.E.R.T. in, , 207 A.W.A.R.E. and, Errors. See also Medication errors; Medication safety. from human factors, from negligence and misconduct, 279 impact of, 279 in blood transfusion, , 184

3 285 in hospital staff nursing practice, 280 in patient identification, for blood ptransfusion, 181, in planning and plan execution, 218 patient factors in, 281 patient harm from, 281 registered nurses, factors associated with, staffing-related, 281 system factors in, wrong drug, H Hemolytic transfusion reaction (HTR), morbidity and mortality from, symptoms and laboratory findings in, 181 Human factors, in errors, in incompatible blood transfusion, in team work, 254 Human factors analysis, of medical devices, design and use of, training for use of, I Intensive Care Delirium Screening Checklist, Intensive care unit delirium, age and, assessment of, barriers to implementation of, 175 assessment tools for, 161, Confusion Assessment Method for the ICU, Intensive Care Delirium Screening Checklist for, study of agreement between, 167 barriers between patient and pratitioner in, , 175 champion representative for prevention and treatment programs, dexmedetomidine impact on, 164 environmental modification for, 169 environmental risks for, ICU care and, 169 incidence of, morbidity and mortality from, risk factors for, sedative agents and, 164 subtypes of, treatment of, atypical antipsychotics for, 171 haloperidol vs., dexmedetomidine for, 174 haloperidol for, nonpharmacologic, , 175 pharmacologic, Interdisciplinary healthcare teams, building of, for patient care quality and safety, conceptual model of, influences on collaboration in, interpersonal processses in, increasing effectiveness of,

4 286 Interdisciplinary (continued) research studies of, attitudes of team members on, 273 cross-functional psychiatric treatment, interdisciplinary vs. traditional rounds, 273 limitations of, rehabilitation teams and outcomes for stroke patients, 272 relationship between group functioning and outcome, 272 relationship between group functioning and standardized mortality ratio, 272 team development training effect on, study of mean LOS on acute care medicine unit, alternative outcome variables and, definitions in, 274 design of, 274 for intervention and reversal months, insights for future research, interdisciplinary rounding in, preexisting, 277 team development training in, vs. standardized mortality ratio, 277 Interdisciplinary teams, relationships in, to improve safety on NICU and ED, L Labeling, for error reduction, 196 risk for error and, M Magnesium sulfate, risks in perinatal patients, Medical devices, challenges of, 233 design analyses of, device-specific, design flaws and safety improvement for, device combinations with alarms, infusion pumps, , 239 safety-enginered syringes, 234, steps in, tubing connections, 234, 238 human factors analysis and, for equipment selection, 240 for existing equipment, 240 for training and work design, human factors and, in design and use error, realistic vs. ideal use in, 239 training in, human factors in use of, use errors with, common and common contributing factors, 237 design approaches to, hierarchy of addressing, 238 Medication errors. See also Errors; Medication safety. ER case studies and safety solutions, improper dose/quantity, in administration phase, in ER setting, , case studies of,

5 287 reducton of, systems approach to, medication use process, 192 reduction recommendations for, automated dispensing devices, labeling and, 196 patient ID and, 195 pharmacists in ED, 195 verbal orders and, 195 with high-alert medications, 195 risk with drug nomenclature, labeling, and packaging, wrong drug for condition, 194 wrong product, 192 Medication safety. See also Errors; Medication errors. for off-service perinatal patient, drug information accessibility for, 222 high-alert drugs and, 222 IV medication risks, risk reduction measures for, 222 system-level risk prevention, wrong drug error risks, nurses and 5 R s for, Morbidity, correlation with ICU delirium, perioperative b-blockade and, 212 Mortality, from medication errors, 191 ICU delirium risk for, perioperative b-blockade and, 212 transfusion-related, 179, N Neonatal intensive care unit (NICU), building team relationships to improve safety, Nurse/patient ratios, for staffing, 262, 267 Nurses descriptions of working together, implications of, need for clear roles and responsibilities, 258 opportunities to learn strategies for, 258 organizational support, 258 training for, 258 in ED and NICU, study of, data analysis in, design, setting, participants, data collection in, theme results of study, concurrence among members, 257 development and maintenance of relationships, personal and professional attributes, 256 vs. teamwork, 255 P Patient-centered care, consumers questions about care, core concepts of, 229 description of, 228

6 288 Patient-centered (continued) framework for redesign of health care, 228 partnership between consumers and providers in, patient advocacy groups, 230 patient needs in, recommendations for, 229 rules in health care reform and, 228 shift from caregiver to patient control, Patient identification, barcode systems for, error in, ABO-incompatible blood administration and, 184 lapse errors in administration of transfusion, 181 recommendations for reduction of medication errors, 195 Patient information, for off-service perinatal care, gestational age, 219 laboratory data, pregnancy-specific, 220 pregnancy norms and reportable warning signs by trimester, 220 pregnancy status, Patient safety, organizational strategies, comparison of staffing plans, 265 policy initiatives for safe staffing and, 267 Perinatal patients, in critical care setting, safe care of, in ER or ICU, errors in plan execution in, 218 planning errors in, 218 IV medication risks and, formal failure modes and effects analysis, 224 isotonic fluid and magnesium sulfate bags, 223 with magnesium sulfate, risk reduction in off-service care, communication in, fetal surveillance, developmentally appropriate, 221 medication safety in, patient information in, Perioperative b-blockade, and postoperative cardiac risk reduction, disparity in the literature, 213 identification of at-risk patients for, mortality rate study of, 212 recommendations, 213 current literature, in high-risk patients, 212 randomized, controlled studies of, scientific evidence for, guidelines for, Agency for Healthcare Research and Quality report, 211, 213 American College of Cardiology/American Heart Association, 211, 213 Physicians, on interdisciplinary teams, 277 Q Quality care, teamwork for, Quality outcomes, communication in coordination of care and, 259 S Short staffing, organizational strategies, alternative staffing models, contingency staffing, 264 nurse staffing committees, 264 patient safety and,

7 289 policy initiatives for safe staffing, 267 strategies for nurse, clarification of circumstances of assignment, competence and acceptance of assignment, 264 identifing situations of concern, 263 threat to patient safety, Staffing. See also Short staffing. inadequate and safety, Institute of Medicine report on, 262 nurse/patient ratios in, 262, 267 patient safety and, skill matching in, 262 T Teams, deep-level composition of, 254 Teamwork, human factors in, 254 W Wireless electronic transfusion verification, for blood transfusion safety,

Patient Safety Overview Muhammad H. Islam, MBBS, MS, MCH Director of Patient Safety & Patient Safety Officer SUNY Downstate Medical Center, UHB

Patient Safety Overview Muhammad H. Islam, MBBS, MS, MCH Director of Patient Safety & Patient Safety Officer SUNY Downstate Medical Center, UHB www.downstate.edu/patientsafety Definitions Patient Safety