Readership Survey for Nurse Advise-ERRT

Total: 1387
1. The newsletter increases my understanding of the causes and prevention of errors.
2. The recommendations for error prevention are practical and helpful.
3. The information is relevant to my practice.
4. The content stimulates discussion among my colleagues.
5. The newsletter helps me use technology more safely in my everyday practice.

6. I have used information from this newsletter to:


   a. Make changes in my workplace

NA 16%
No 16%
Yes 65%
Yes, No, NA 0%
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.
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
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
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
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
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.
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.
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
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.
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
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.
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!!!
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.
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.
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.
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.
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.
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!
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
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 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
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.
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

NA 19%
NA, No, Yes 0%
No 14%
Yes 59%
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.
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"
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
I am More Careful to check orders
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.
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.
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.
More cautious when reading physician medication orders. Questioning more often if unsure of the meds or of the spelling.
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.
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.
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
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
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
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.
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.
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.
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.
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.
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
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.
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.
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.
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
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

NA 16%
No 20%
Yes 55%
Yes, No, NA 0%

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.
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.
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
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)
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.
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.
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.
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.
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
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.
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.
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.
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 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)
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.
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
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!
Examples of the errors and the recommendations to avoid future errors.
All very helpful especially with the mediation reconciliation initiative we are embarking upon
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
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
Everything overall seems useful.
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? can we prevent it?
Error prone drugs. Safety suggestions
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
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
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
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
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
labeling of medications on steril fields
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.
medication info
look alike products,minimize calculations,unit dosing
medication issues
Devices connecting to needleless IV ports. The articles on the PCA pumps and drug administration.
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
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
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.
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.
Reading about products that appear identical based on the initial labelling.
Home Care applicability
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
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.
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 topics have been found to be useful, sometimes the information is already known but it serves as re enforcement.
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
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
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.
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
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.
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
Most issues very relevant info
Stories relating to drug errors.
importance of all containers to be labeled
Every issue is useful. I would not know where to start.
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
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
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
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
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
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
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.
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!
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
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.
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
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.
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
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
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"
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
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
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 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.
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
look alike vials for injection
System errors and need for tracking to make safer practise environments
all of them
the various topics
Avoiding medication errors
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
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.
Actual examples of problems
types of errors, error examples, approved abbreviations vs. banned abbreviations
safety and prevention
med or ideas on how to prevent the same errors from happening in my facility
Prevention of errors
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
information on drugs
predication errors
the part about the flammables
Importance of labeling EVERYTHING!
examples of errors that occurred
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
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:
All topics are very good.
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.
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.
Computer / bar code .... not a factor in my workplace.
Hospital based solutions. I work in home care.
the long articles
Anything to do with hospital concerns.
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 at this time
I have saved every copy. I can't remember any that I didn't find something useful.
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
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
We all know that intimidation happens. Would be nice to include how some places are able to decrease it.
have not found anything to be "least useful".
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
infrequently used drugs
Involving errors in surgey and ICU units.
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!
can'tthink of any
I have found each newsletter useful.
those not relevant to my practice as an ED nurse.
The idea that in OR the open containers are not already labeled??!?!?!!!?
i find it all very helpful
don't work in area where many meds are given - still found specific situations very interesting.
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.
Most interviews
Can not think of any @ present
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
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.
n/a Even the topics that don't affect me directly, I find interesting. They may help me in the future to avoid problems.
don't remember
We don't use PCA
I haven't found something that I cannot use in some way or another.
None. It is all useful
As above do not have information on this newsletter
Discovered a medication error in the newletter so I have not been that fond to reading additional articles
med error in newsletter
Feeding tube and interaction. I work in a clinic. But can be very good info for log term case or ICU
OR error articles, only because it doesn't apply to me, but is still good info nonetheless.
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.
State Board of Nursing inquisiton article was confusing to me
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
Long discussions of errors related to drugs not on our formulary
Whole issue is helpful
IV pump info
It is all helpful.
I found everything useful.
Computer dispensing systems. There are many different types available
Not many.
IV drugs
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
See number 7. Since all were useful, none were least!
you can glean something useful from every article
None. I think it is better to be informed of problems in all areas of practice.
All useful
I do not work in a hospital/high level medical needs situation. More interested in day to day medication administration
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.
all useful
Operative/perioperative issues simply because we are a LTC facility.
None - keep up the good work.
Still interesting
so far all have been interesting. However the newsletter is forwarded. I would like to have direct access.
Topics on outpatients
None. I read it all
None, please keep up this tremendous resource coming.
Didn't find any topics that were not useful
Can't think of anything
I did not find anything that is not useful.
I find all topics worthwhile.
all have been useful
Some of the totally bizarre incidents--staff have questioned the actual occurrance
Chemo drug info.
None. Each has a point to make.
None that I can think of.
I read it cover to cover. I have discovered that the information I find not to be useful at this time usually presents with an opportinity down the road.
flammable materials
none - always learn from your newsletter - information applicable somewhere in my facility.
All are interesting
ones not dealing with my regular work area -- not surgical
none all are beneficial to read
All were useful
Pediatric/neonate items just b/c this isn't my specialty.
I haven't really found anything that isn't useful either to myself directly or to my staff (which I then pass along to them frequently).
interesting but not pertinent to my practice
operating room
Everything has been well-written and valuable! Thank you!
Information about a conference. ( I can look that up on the web)
things related only to a hospital since I work in outpatient
OR issues
Please include more home care suggestions.
Baxter pump
All are relevant and interesting
none yet
Topics only relevant to nursing.
though labeling is indeed important, I generally practice it already
Med specific- again, not from a medically-oriented unit
Articles regarding surgical protocols as it we do not have that in our facility.
I have founs the whole newsletter informative.
OR and ER are not in my realm of practice.
I do not work in an OR area
Almost all the topics are useful and practical.
Almost all the topics are useful and practical.
interesting, but not as useful, items pertaining to hospital based practice
None I can think of at the moment
I HATE the title. I am afraid it will be self fufilling. It's a non-profot organization right?
I work in Home Care-the issues there are very serious-patients sent home with a list of medications from the hospital that do not match what they are taking at home. Some are generic and the patient has no way of translating. It is a very serious issue
Topics relative to surgery
idealistic practice modalities. too simplistic.
The flamable products topics were least useful this month.
OR topics
I can't recall any.
format in which the newsletter comes up on the computer, distracting to need to scroll up and down to read pages
Issues related to handwriting as we have an entirely electronic medical record.
Much of it is not applicable to home health which my area of practice
Everything was useful
I find it all useful.
Going on and on about how a med works. Just a brief note is enough.
It's all good!
nothing - newsletter is short enough to keep interested
Computerized systems, unit is not computerized
infusion pumps-not used in my clinic area
I would like to see the information in a two page format. That way I could copy on front and back and distribute to staff. Many times it is one three pages.
I found most of the articles very interesting
Most everything I've read has been usefull in some way or another.
None. I read it front to back so that I won't miss anything.
Sometiomes there are specialty specifc meds I don't use, e.g. chemotherapeutics. Intersting info, just not currently useful.
It is all very relevant.
Some American only content is not applicable in Canada
Enjoy it all
Nothing yet
Things that are not applicable to our practice setting...but that's o.k., it still may apply when we are practicing outside our primary work setting.
Those issues regarding IV infusions have not been as helpful, but when I receive them I determine if they are relevate to our operations and incorporate this into monthly education.
Medications that we cannot relate to in an ASC setting.
All topics thus far I have found to be informative.
I like everything and I learn from everything
I find it a bit insulting when you reference something that was recommended in back issues, like a one time recommendation made in an issue from a few years ago will fix things. What about those people who never got to read that issue! I wish you would work more closely with manufacturers to do better labeling at that time that you first id the problem. That upstream change would help lots of downstream users.
If the topic is not applicable, then the safety examples have been helpful.
none,all very useful
all the information was useful
Not a thing
Examples that are presented more than once in the newsletters i.e. examples of poorly written medications
All information was helpful Thank you
Things related to specialties that are not at the facility I work at (e.g. perioperative)
Those that pertain primarily to hospital-based issues
Pediatric related
i have to scale the advice to medication technicians, as i am a supervising group home RN, & deal with med errors more often that i would like to. The caliber/education/literacy levels of the med "techs" is not the highest, so I am constantly on edge & watchful for errors. In this day of cost cutting , I think that may be the situation more often than not. adjusting the advice to a level of understanding by non professional people, entrusted to administer meds. getting the message across clearly, but then, it is called a NURSE ADVISER newsletter. i still get a lot out of it.
cultural diversity; safety issues, etc
It was all very interesting and easy to read.
All your topics are helpful and valuable to our facility!
Discuussion on Flamable liquids --- however I appreciate the reminder -- somethimes I think we all get too comfortable with solutions and don't appreciate their dangers
All the covered topics were very useful.
There were only two articles, protonix and cultural diversity issues.
All indormation has relevance in some way.
it's all informative
The only thing not useful to me is the discussion of drugs, etc. not avaialable in Canada
Can't say. Hospital Issues don't related but still interesting.
None really
Medications used in radiology, such as, Interventional Radiology.
All seems useful
computer errors because I don't work with computers in my work area with the students.
Ambulatory info.
I really find it all useful
Haven't found a topic yet
there weren't any
All useful at some level
None, noted.
Not sure, but as long as they contribute to what is considered "best practice" they could be used.
needn to read more issues
Meds not used in L& D
did not received last month newsletter
pump issues
the OR piece
not much
none. all very useful
Areas that didn't pertain to my department, e.g. surgery or anesthesia

9. Do you have access to the Internet to download the newsletter if it was provided monthly via an email message with a link to our website?

No 3%

Not sure 3%

Yes 89%
Yes, Not s 0%

10. What is your profession?

Nurse 88%

Other 5%

Pharmacist 2%
Physician 1%

Other (specify):
Pharmacy Technician
RN & Risk Manager @ an insurance company
QA/RM Coordinator
Project Manager in Quality
Quality Improvement Advisor
Risk Manager
Administrative Assistant to VP for Nursing
Patient Safety Manager
Clinical educator
Nurse practitioner
Coordinator, Accreditation and Regulation
Manager of Nursing Standards
Director Quality, Pt Safety
Health Services Researcher
Educator - professor of pharmacology
Risk Manager
Director of Women's Center/Pediatrics
Patient Safety
Nurse practitioner
Risk Manager
Clinical Educator
Nurse Practitioner
Project Director, Patient Satisfaction
Clinical Nurse Specialist
Installation Consultant
compliance officer
LNHA Associate Administrator
Patient Safety Goals Officer - Licensed Respiratory Care Practitioner
Nurse Practitioner
Family Nurse Practitioner
Critical Care
Clinical Nurse Specialist
Health Informatics Specialist
risk manager
CQI Manager
Nurse Practitioner
Clinical systems analyst
Clinical Educator
Perinatal Clinical Nurse Specialist
staff RN
Risk Manager/Patient Safety
Pt Safety/QM Specialist
Infection Control
Nurse Practitioner
claims investigator/ risk manager
Clinical Nurse Coodinator Orthopedics.
Staff orientation and education
consultant for LTC Pharmacy
Diabetes Nurse Expert
PAtient Care Safety Officer
Registered Respiratory Therapist
Clinical Informatics
Risk Manager
Corporate Risk Manager
Nurse / Attorney/ nurse consultant
Clinical Performance Improvement Specialist
Faculty BSN program
Health Facility Evaluator
risk mgr
Administrator for a for profit surgery center company that partners with physicians to own and operate their own ASC
Nuring Faculty
Staff Development
Clinical Risk Manager
Nursing-Pharmacy CQI Committee members (includes pharmacists and nurses - we completed survey as a group)
Nurse Educator
Clinical Nurse Specialist
Staff and Educator
Performance Improvement
Coord.of Clinical Education and Patient Safety
Risk Manager
Legal Nurse Consultant
family nurse practitioner
Family Nurse Practitioner
Medication safety specialist
educator and hospital supervisor
OR Educator
Clinical Educator-
Nurse Manager for OB and Pediatrics
surgical technologist
Case/Risk Manager/Infection Control
Performance Improvement
Clinical educator
Nurse and Systems Engineer
OB clinical educator
community medicine
Registered Nurse
QA Manager
nurse practitioner
Risk Manager
Director of Qualilty Mangement
Ambulatory Surgery
Combat Medic
nurse educator
Nurse Manager - PICU
Nurse Case Manager
Nurse, risk/quality manager, legal nurse consultant
QI Coordinator
Nursing Performance Improvement Manager
Clinical Nurse Educator
Staff Development Educator
Director of Women's Center/Pediatrics
Team Leader for Emergency Response Team
Soon to be Nurse Practitioner
Risk Manager
healthcare Risk Manager
community college nursing faculty
Neonatal Nurse Practitioner
Nurse Practitioner
school of nursing instructor
Patient Safety Manager
Patient Safety Manager
college professor
Inpatient Nursing Supervisor
nurse practitioner
Quality Improvement Director
quality consultant
Nurse Manager / Director of Nursing
Risk Manager
Pt Safety Officer
RN Emergency Room
Clinical Educator
Certified Diabetes Educator, Certified Pump Trainer
Risk Mananger
clinical educator
manager high risk ob-gyn
Clinical Med/Surg Educator
staff and patient educator
Service Coordinator
Clinical Educator
Nurse Manager
Risk Manager Long Term Care
RANC student
Nursing Faculty
Coordinator of PN program
RN and Certified Health Education Specialist
staff educator
Trauma Program Manager
Clinical Quality Specialist
certified cv rn,sr professional staff nurse
& nurse educator
staff nurse hospital and lab instructor
ED department
Cinic Nurse Coordinator

11. At what level do you practice?

Administra 13%

Manager 25%

Other 24%

Staff 28%
Student 2%

Other (specify):
Clinical Outcomes Coordinator
RIsk Manager @ an insurance company
Clinical Project Manager, CPI
Project Manager / Adm Projects
Clinical Nurse Specialist
staff development educator
Also nursing student
Advanced Practice Nurse/Educator
Interim manager/full-time educator
nurse educator
Clinical Nurse Informaticist
Charge Nurse/Nursing Quality Improvement coordinator
My position is considered management level
Nursing PI Coordinator
Quality Managment
Education Specialist
NP and Pain Mgt
School nurse
Nurse Educator - CVICU/MICU/Cardiac Interventional Services
Nursing Quality Coordinator
Clinical Staff educator
Quality facilitator
I teach at 2 schools of nursing & give study days for practising nurses.
staff education
Nursing Quality and Performance Improvment Coordinator
education facilitator
Clinical Nurse Specialist
Risk Manager & Patient Safety Coordinator
Nursing Standards Coordinator
Advanced Practice Nurse & Educator
NUrse Staff Instructor
education coordinator
Clinical Nurse Educator
and staff too
Nurse Educator
nurse informaticist
Work for healthcare software vendor
PI Coordinator
Nurse Quality Analyst
and educator
Nurse Educator
Education Coordinator
Clinical Nurse Specialist
clinical manager
bedside RN and proud of it! in Critical care
Risk Management
Clinical Nurse specialist
Nursing Education
Somewhere between staff and manager
Clinical Educator
assistant professor of peds nursing
Healthcare Consultant
Nursing Faculty
Staff Development/Patient Educator
Academic Educator
Staff Educator
Charge nurse
infusion specialist
Clinical Educator
Refugee Clinic Consultant/Staff
Clinical Information System
clinician, educator
Clinical Nurse Educator
Director Clinical Informatics
Process Improvement
psychiatric unit
nursing professor
Info above from staff since Nurse Advise ERR is not available to them.
Nurase Practitioner
Clinical Educator: MSN prepared
Nursing staff education
clinical educator plus staff nurse
Advanced Practice Nurse
Clinical Educator for Staff Development
Administrative Staff Nurse
Clinical Instructor
Performance Improvement Director
Advanced Practice Nurse
Nursing Coordinator
Clinical Quality Resources
also clinical educator
Clinical instructor in school of nursing
insurance company
staff development
Education Manager
Community Health Nurse Coordinator
Quality Advisor
Performance Improvement Clinical Reviewer
CBOC (Anaheim)
Admin. Director
Performance Improvement Coordinator
Staff Development Coordinator
nurse informatics
Nurse Educator/Clinical Faculty
RN educator
NP and Nurse manager
Clinical educator
Quality Improvement Coordinator
Performance Improvement Director
Occupational nurse
And Staff
teach patients
Clinical Informatics
clinical nurse educator
Assistant Professor, School of Nursing
CNS, Consultant
Director of Nursing
Quality Manager
Educator of Hospital Nurses
Director of PI
Patient Safety/ Risk Management/Quality Improvement
Nursing Supervisor.
school nurse
Self employed consultant
Charge nurse, Postoperative unit
Clinical Leader
Quality Improvement
Pharmacy Nurse Liaison
Clinical Nurse Specialist.
also LPN instructor
Clinical educator
RN Educator for the Imaging Department
Clinical Nursing Instructor
educator and supervisor
Medical Reviewer
Computer Order entry and Documentation Support
Faculty in Acute care setting
regulatory enforcement
Home Health
Nursing Instructor (part-time)
Nursing Instructor
Education all disciplines in HC
Service Coordinator
Risk manager
health educator
Patient Safety Officer/Risk Mgr
Committee - leadership and staff
manager level with patient care
Educator and functioning CRNP
associate unit nurse manger
Nursing faculty
Staff development
in house newsletter editor
Patient Education and Staff Development
Staff Nurse in Critical Care
Lead RN
Sole Proprietor of my business
Perioperative Clinical Nurse Specialist
Not in clinical area
disease management RN
Clinical Educator
Clinical Coordinator
Professional Nurse Educator
RM/QI coordinator
Health Care Provider
Vendor company
Clinical Nurse Specialist
clinical nurse educator
Instructor, College of Nursing
Quality Performance
Supervisor and active with med safety
Education coordinator
Project Manager, Clinical Documentation
Geriatric Case Manager (no hands on nursing)
faculty and supervisor
Educator / Faculty
Also manager
Parenteral Therapy Nurse Coordinator
see above
Staff & Manager
Risk Management
Dir of Education
Clinical Educator/quality/ administration
and Educator
Chart auditor for a financial intermediary agency
Nursing Analyst - I.T. Department
nurse practitioner
clinical educator
consultant for healthcare company
Medical Device Manufacturer
clincial educator
staff development
nurse manager,community health center
Nurse educator
professor and staff nurse
RN Director
Clinical educator
Education Specialist
clinical quality
In charge when Manager is off
staff and educator
Clinical Nurse Educator
Clinical Education Specialist
Nursing Educator
Clinical Specialist
nursing education specialist
Resource Nurse for NICU
CEO of my own company
nurse educator
Regulatory - Survey Agency
Sr. Director of Clin IS and Training
nurse expert/Diabetes
Risk Management
educator and staff
Nursing Quality Coordinator
LTC Educator/Manager
Staff Development Educator
Educator, Faculty
Clinical Nurse Specialist
Direct Report to Department Director and Physician Intensivist
Nursing Instructor
Clinical Leader (Staff Nurse III)
Director and educator
Nurse Educator in University
Nurse Educator
Nurse Instructor
Chief Nursing officer
CQI coordinator
Clinical Education Consultant
Clinical Nurse Educator
nursing faculty
supervisor of in unit (nurses)
Nurse Educator in Nursing Education
Neonatal Nurse Practitioner
Director of Pharmacy
clinical educator and infection control nurse
PI Coordinator
PI coordinator
Education Coordinator
clinical faculty
Nursing Supervisor&Perform. Improv
Staff RN/Nurse Educator
QM Nurse Consultant
Infection control nurse
Public Health
Nurse Educator
Supervisor of Nurse Managers
Clinical Educator
Nurse Educator
Director clinical education/staff development
Clinical Educator and staff nurse
Quality & Safety Project Coordinator
and nursing instructor.
D/C Planner & Case Mgmt.
interim manager of Progressive Care Unit
Diabetes Nurse Educator, Community Hospital
supervisor, main pharmacy
ambulatory educator for 50 clinics
Clinical Nurse Educator
Staff Educator/RN
Nursing Instructor in a Community College setting
clinical educator
and staff nurse
Clinical Educator
Pharmacology Instructor for LPN program
Management of Ancillary Staff
nurse educator
Risk Management
Compliance Coordinator Pt. Safety Officer
Director of Education at a hospital
Staff Development
RN Director
Qualty Management
Performance Improvement
Nursing Informatics; Bar Code Medication Administration Coordinator
supervising RN- developmentally disabled residents, with 24 hr direct care staff, very diverse staff population
Risk Management Consultant
Educator in community College
Nursing Faculty
Quality Improvement Nurse
staff 2days aweek /management 1 day
staff 2days aweek /management 1 day
charge nurse
(former manager)
Non-Invasive Cardiology Special Procedure Njurse
clinical nurse specialist
Nursing Faculty
educator and clinical instructor
Nursing Educator
Clinical Nurse Educator
Gerontology Clinical Specialist
Theory and clinical vocational nursing instructor
periop nurse educator
Some patient care responsibilities
clinical nurse educator
Clinical Nurse Specialist
clin spec
Infection Control Nurse, Nurse Educator, Quality Coordinator
Senior Program Coordinator
Perioperative Educator, Surgical Services
CNS Advanced Practice Nurse
I teach for the College of Nurses of Ontario
Perioperative Education Coordinator
nursing school lab instructor, and hospital nurse
Registered Nurse/Agency
and QI representative for the ED
Specialty Nurse
Clinical Nurse Specialist
Clinical Educator / Parent Educator
staff development

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