by
Lauren Dubinsky, Senior Reporter | April 06, 2015
In addition, someone should be assigned to go through the medication list to ensure there are no dosing errors or duplicate orders for similar drugs with different names. If the patient is discharged to a nursing home or subacute care facility, medication reconciliation needs to be managed in both settings.
When two practitioners perform an independent double check of the blood group before transfusion, sometimes it isn’t done in a truly independent manner. To change that, organizations need to educate their staff about why it’s important to do it independently and also have good judgment about which processes require independent double check to prevent double check fatigue.
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When it comes to opioid-related events, two issues are of most concern. Physicians sometimes prescribe the same amount of hydromorphone as morphine even though it is about seven times as potent, and physicians occasionally won’t distinguish opioid-tolerant patients from opioid-naive patients. To prevent that, physicians need to be educated more about opioid safety.
For six years in a row, reprocessing has been on ECRI’s top 10 health technology hazards lists. The process of reprocessing surgical instruments is difficult and time-consuming but it must be done properly from start to finish.
If the instruments are not thoroughly cleaned, organisms will remain on them and if they’re not dried in the final step, they become a breeding ground for organisms to grow. Also, organizations must follow the different cleaning, disinfection and sterilization instructions for every type of instrument.
When a patient is being transported within a hospital or to another care setting, the appropriate resources and requirements for each individual patient must be identified. In addition, event and near-miss reporting systems should record transport-related incidents to spot gaps in policies, procedures or training.
Sometimes organizations have mix-ups between pounds and kilograms when weighing patients for medication dosages. To solve that issue, ECRI recommends getting rid of scales that measure in pounds or adjusting electronic scales so they only display in kilograms.
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