gentamicin hospital error pdf Wolcottville Indiana

Address 671 Dowling St, Kendallville, IN 46755
Phone (260) 349-0170
Website Link

gentamicin hospital error pdf Wolcottville, Indiana

In the analysis of weight-based dosing errors reported to the Pennsylvania Patient Safety Authority, half of the top 10 medications associated with these errors were high-alert medications, as shown in "Top J Emerg Nurs 2009 Nov;35(6):553-5. The weight at which gentamicin needs to be prescribed is the patient's own body weight. Lerner, PhDAnthony J.

A baseline study demonstrated that dosing was only being carried out correctly 30% of the time. It is presumed that this is a safer and more effective way of giving the antibiotic. If actual weight is used instead of ideal weight, which is calculated based on the patient's height, an obese patient could receive too much medication. Providers must be vigilant in recording patient weights accurately and in kilograms.To ensure accurate weight-based dosing, organizations should harness the capabilities available in electronic systems.

Your recipient must be a current subscriber to this ECRI product in order to open or save the e-mailed article. Accrediting organizations and the Centers for Medicare and Medicaid Services (CMS) have established requirements for patient weighing. Additionally, any verbal communication involving a patient's weight should use metric units as a standard measure. In fact, in one study, mathematical incompetence was a significant source of error in tenfold medication dose mistakes (Doherty and McDonnell).

ECRI Institute PSO examined events of weight-based dosing errors that were reported to the event reporting system from September 1, 2012, through August 31, 2013, and that indicated the level of The reports of weight-based dosing errors submitted to ECRI Institute PSO reflect three general concerns surrounding weight-based dosing errors:Failure to obtain or document an accurate patient weightMistakes that arise in using The height and weight of patients is nearly always guessed or approximated which means that patients can be severely underdosed or overdosed. A snapshot look at medication errors reported to ECRI Institute PSO over a one-year period shows that weight-based dosing errors occur among patients of all ages.

For these patients, body surface area may be used to calculate medication doses. Previous SectionNext Section Background Gentamicin is an antibiotic from the class of aminoglcosides. The systems can also be programmed to not automatically repopulate data fields with the patient's weight from a previous admission in order to prompt caregivers to obtain the current weight. High-Alert MedicationsIn the analysis of weight-based dosing errors reported to ECRI Institute PSO between September 2012 and August 2013, several of the events that resulted in patient harm involved high-alert medications,

The use of two nephrotoxic agents led to toxic levels of the drugs. The report found that 5 of the 10 medications were high-alert drugs, which have an increased risk of causing patient harm if used incorrectly.Heparin sodium*Enoxaparin*AcetaminophenDobutamine*Dopamine*Gentamicin sulfateVancomycinIbuprofenNesiritidePropofol** High-alert drug Source: Medication errors: Intern Med J 2007 Sep;37(9):647-50. Additionally, pharmacists should review all medication orders that require dosing on the basis of patient weight and independently double-check the dose needed for certain medications (e.g., medications dispensed for pediatric patients,

PubMed:; Royal College of Nursing. Glossary Glossary References Bibliography Bibliography References References42 CFR § 482.25 (2013).Clarkson DM. These drugs bear a heightened risk of causing significant harm when they are used in error (ISMP "ISMP's List"). Strategies to Prevent Weight-Based Dosing Errors by Strength of Impact" for a summary of these prevention strategies, grouped by hierarchy as an error-reduction technique.

Many healthcare settings also obtain patient weights in pounds. They are all ways in which the use of computerized provider order entry systems can lead to medication errors.Earn AMA PRA Category 1 credits! Facilities that provide pediatric care must provide weighing scales designed for infants and children. There is always a need to refine and optimise systems and this project has demonstrated just that.

The patient's blood pressure dropped.The patient, who was morbidly obese, had an acute pulmonary embolism. Other mistakes occurred as a result of incorrectly setting infusion pump rates or giving an extra drug. By not following this protocol significant variation can occur in dosing and subsequent prescription. Comprehensive accreditation manual for hospitals.

Subscribers have access to learning resources, case examples and an on-call faculty of experts who are available to help. Articles by Grundy, D. But in this particular case, the ED provider's weight estimate did not closely match the patient's actual weight. Bruley, CCEPeter Catalano, MBA, CPAJames P.

One study found that fewer than 30% of patients in a hospital's orthopedic and medical units were being weighed, even though they were taking medications that required weight-based dosing. Clive Grundy Correspondence to Dr. To accomplish these goals, organizations must strive for strategies that achieve the following:Establish processes for weighing and weight documentationRequire pharmacy review of weight-based dosing regimensEnsure sufficient and convenient availability of appropriate All rights reserved.About us · Contact us · Careers · Developers · News · Help Center · Privacy · Terms · Copyright | Advertising · Recruiting We use cookies to give you the best possible experience on ResearchGate.

If the errors are not caught, the automated dose calculation features provided with many health information technology systems will end up calculating doses based on an incorrect value.In addition to weight, Failure to Obtain or Document an Accurate Patient Weight ​ ​ ​ Event Type Event Description Patient Age SettingEstimated weight used as actual weightThe medical record did not indicate that the If caregivers relied on their best guesses of a patient's weight, they would only be right 60% of the time (Clarkson).Two other events involved children. The system returned: (22) Invalid argument The remote host or network may be down.

The converter would help to overcome this problem. The correct gentamicin dose was calculated for each patient and compared with the dose which had been prescribed and dispensed. PubMed: E, Williams R, Cousins D. The findings were that gentamicin had been correctly prescribed in 92% of cases, demonstrating a 300% improvement in dosing.

Invalid Email Format Recipient's email address * Email is required. Find out more about BMJ Quality Improvement Programmes >> Navigate This Article Top Summary Problem Background Baseline Design Strategy PDSA Cycle 1 PDSA Cycle 2 PDSA Cycle 3 PDSA Cycle 4 Child (1 to 12 years)EDWeight incorrectly documentedThe wrong patient weight was entered into the electronic record. Pharmacopeia's Medication Errors Reporting Program between January 1, 1995, and December 31, 1999, found that dosing errors represented 47% of all pediatric medication errors and 28% of all nonpediatric drug errors.

Generated Mon, 17 Oct 2016 05:37:18 GMT by s_wx1131 (squid/3.5.20) ERROR The requested URL could not be retrieved The following error was encountered while trying to retrieve the URL: Connection Practices for Obtaining and Documenting Patient WeightThe organization's policies and processes for obtaining a patient weight should establish the timing and frequency for patient weighing. Previous SectionNext Section Strategy See supplementary file: CalcScreenshots.docx PDSA Cycle 1 The calculator was initially shown to the consultant microbiologist in charge of antibiotics within the trust as well as the The system returned: (22) Invalid argument The remote host or network may be down.

CrCl is not a measure which is provided with the rest of the blood results and it must be manually calculated. Search for related content PubMed Articles by Qureshi, D. Imran Qureshi, reachimyq{at}  Next Section Summary Gentamicin is an amino glycoside antibiotic, which is used predominantly in gram-negative infections but also has anti-staphylococcal activity. These calculations involve knowing the patient's height and weight and this can be a significant challenge, especially if the patient is bed-bound.

These features include child-specific medication libraries, normative references, and child-specific weight-based dose calculations and alerts. Also available at PubMed: SN, Rangiah C, Bajorek BV et al.