Institute For Safe Medication Practices

Readership Survey for Nurse Advise-ERRT

Total: 1324

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

16%

77%

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

21%

72%

3. The information is relevant to my practice.

10%

20%

66%

4. The content stimulates discussion among my colleagues.

21%

26%

46%

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

17%

25%

52%

6. I have used information from this newsletter to:

a. Make changes in my workplace

16%

17%

Yes

64%

If yes, please provide examples:

Sharp injury prevention; PCA usage

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

Separate look alike/ sound alike meds from floor stock

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

Improve medication administration safety & competencies

Powerpoint presentations for staff development - communicate actual & potential errors

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

Ensuring safety with verbal orders

Examples of errors to create learning opportunity

Sound alike drug. Labelling IV lines with medication names

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

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

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

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

intimidation

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

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

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

double check practices for IV and other medications.

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

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

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

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

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

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

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

Used information to implement and enforce National Patient Safety Goals

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

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

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

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

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

handwriting, look alike sound alike

Improved safety awareness of nursing staff

orientation of new staff especially new graduates.

Policy changes about medications. Not abbreviating medication names.

start safety walk arounds in my facility

to emphasize the importance of writing legibily

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

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

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

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

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

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

Provides a resource for policy and decision making

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

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

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

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

Changes PCA Pump procedure to incorporate recommendation for PCA by proxy

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

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

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

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

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

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

Helped in policy revisions with PCAs.

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

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

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

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

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

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

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

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

Look alike - Sound Alike medication arrangement in the pharmacy

Changed policies to reflect recommendations

test

Tall man lettering

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

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

Pca by proxy policies and education

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

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

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

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

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

improvements in labeling and identification, and handling of medications

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

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

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

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

Tallman labeling of computer listing of medications

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

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

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

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

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

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

ideas for elimination of "Do not Use" abbreviations

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

policy changes

Revised PCA policy & procedure.

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

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

training of new medication aides and new graduate students

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

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

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

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

labelling of products properly

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

Instituted the Red Vest Program

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

regularly use it to augment our safety meeting

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

PCA programming , is mentioned in our education sessions

My facility has made changes

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

Provided advice to colleages on practices as noted in this newsletter

Implementation of Do Not Use abbreviation policy

Assuring medication labeling is correct.

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

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

Implement policy and proceduresR/T med safety

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

developed do not use abbreviation list,

Just received the first newsletter

First reading

utalize as a teaching tool

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

they validate the changes made.

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

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

We've changed how magnesium sulfate was prepared for nursing

Provide relevant information to nurses.

Incorporating some of the practices into protocol and form development

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

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

increased discussion and awareness of med error issues

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

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

review existing policies and procedures for safe practices

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

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

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

documentation, monitoring, use of abbreviations

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

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

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

Label medications on surgical field

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

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

make me more aware and careful with my practice

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

Look alike sound alike drugs being stored in different locations.

One example followed up on the info regarding Baxter Pumps.

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

PCA pump selection

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

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

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

Label medication containers on sterile fields

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

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

implemented computerized medication application

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

What is taught in inservices and formal school of nursing examples

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

Labeling of medications

Working on pain management assessment forms

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

Moved sound alike / look aike drugs apart

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

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

Content added to Nursing Orientation and discussed at Medication Safety Committee

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

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

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

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

We use this newsletter for guidance when revising policies

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

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

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

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

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

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

posted for staff to read

TO ENFORCE POLICIES THAT PEOPLE DO NOT FOLLOW

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

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

Abbreviations

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

Share in staff meetings for peers and staff.

iv labeling project in critical care utilizing tallman lettering

PCA procedure

Use articles for in-services and risk management

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

pca pumps, policy,procedure, implimentation of new

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

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

Information is passed on to all nursing staff.

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

pca alerts for patient use only

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

Used to update policies

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

awareness of medication errors

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

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

Policy revisions

provide additional verbal cautions to staff

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

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

Checking of high risk drugs prior to administration.

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

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

Changes in PCA policy, protocol and education.

New abbreviation list, look alike packages and names alerts

provide information to co-workers regarding medication awareness

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

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

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

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

Policies to prevent future errors

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

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

Improved awareness of things to watch for in our ED.

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

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

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

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

labeling perioperative meds and solutions

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

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

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

Clear documentation. requesting clarification

I use the information with my nursing students.

now have OmniCell for narcs

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

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

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

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

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

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

Double checks for high alert meds

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

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

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

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

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

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

We now label unmarked syringes with labels made up beforehand

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

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

Change practice implementing information from newsletter.

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

Standard concentrations supported

Safety is part of daily team meeting

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HAVE USE THIS IN OUR NEWSLETTER

Medication safety committee initatives

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

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

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

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

PCA standardsa of care

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

Information in newsletter validates reason for change in practice.

to enhance safe medication practice with students

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

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

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

Labeling solutions on back tables

We revised our class on PCA utilizing information in newsletter

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

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

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

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

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

Heighten awareness of how errors occur.

check it out

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

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

So far things mentioned we had already done.

Labeling all containers

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

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

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

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

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

PCA Awareness

Checked for labelling. Made use of different size bottles.

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

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

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

Information is given to staff via inservices and education

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

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

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

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

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

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

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

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

Support changes to medication practice guidelines

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

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

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

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

Creating medication safety education for staff nurses.

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

Will label 100% of the time vice 95%

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

Included information in my orientation classes.

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

moved meds

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

double checks, non punitive system, therefore more reporting

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

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

Updated list of dangerous abbreviations.

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

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

increase awareness to look alike labeling

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

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

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

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

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

Hospital has made changes with SALA drugs.

managers use this for inservices

Information is passed on to other departments where information is applicable

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

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

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

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

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

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

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

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

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

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

Label

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

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

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

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

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

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

Currently continue to work on eliminating abbreviations as recommended.

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

Avoid abbreviations.

Pain management committee -- P/P changes

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

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

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

writing out words instead of using abbreviations

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

Symlin issues

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

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

Increase discussion of previous medication errors among staff

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

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

Acceptance of verbal orders/use of abbreviations

I post a copy at work for colleagues to read

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

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

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

In policy.

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

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

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

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

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

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

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

Revised our facility policy

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

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

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

narcotic safety ie, cosigning PCA syringes

A copy was given to our radiology nurses

Use w/staff education p&t committee

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

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

our hospital has used pt name and birthdate to id pts

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

Educate staff.

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

separate like-labeled products

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

increase awareness

has brought about much discussion among the staff!

changing locations of med

developed list of do not use abr.

Made changes in medication administration policies

More careful labeling meds

Updated our abbreviations lists

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

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

Open discussion of nurse specific issues in a practice forum.

Decrease use of abbreviations in med profiles and orders

med error tracking

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

ml vs cc medication awareness

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

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

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

moving pre-mixed potassium minibags from regular minibags

Used as educational tool for nurses returning to practice.

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

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

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

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

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

double checks

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

Illegible orders, transcription issues

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

limiting use of certain abbreviations

Implemented safety measures related to PCA pumps.

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

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

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

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

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

labeling meds

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

I use the newlwtter for staff development.

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

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

I work in Alzhiemers research

Things we teach students in skills lab

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

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

staff meeting/safe practice focus

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

changes in storing and dispensing some medications

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

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

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

Engendered discussion

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

We now stock pre mixed magnesium sulfate.

Developed a communication plan for medication errors.

increase staff awareness about medication safety

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

POLICY CHANGES

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

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

Increase staff awareness of medication related errors via patient safety training

We have a pharmacist on staff and it increases our discussions

Provide awareness to issues among colleagues.

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

Reinforce our recent implementation of an electronic Medication Administration record

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

Passed onto other departments and managers

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

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

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

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

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

I review articles at nursing meetings.

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

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

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

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

SOUND ALIKE DRUGS SEPARATED

improved medication reconciliation. improved awreness of potential errors.

Put labels on everything.

support for NPSG

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

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

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

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

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

high alert drugs, sound alike-look alike

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

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

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

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

abbreviation

Not yet!

Has helped us with labeling and storage of medications.

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

update policies and procedures

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

Made a list of sound alike look alike drugs.

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

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

Implemented double checks where they had previously been eliminated.

Medication storage, verification and increase knowledge

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

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

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

aBBREVIATIONS AND cONC. ELECTROLYTES

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

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

employee education

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

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

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

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

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

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

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

engaging the patient and family

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

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

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

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

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

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