New technology, new errors: How to prime an upgrade of an insulin infusion pump

Joint Commission Journal on Quality and Patient Safety

Volumn 33, Issue 3, 2007, Pages 155-162

  Rule, Ann M ^a   Drincic, Andjela ^b   Galt, Kimberly A ^c  

^a CREIGHTON UNIVERSITY SCHOOL OF PHARMACY AND HEALTH PROFESSIONS   (United States)

^b School of Medicine

^c Sch of Pharm and Hlth Professions   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANTIDIABETIC AGENT; INSULIN;

ARTICLE; CASE REPORT; CHEMICALLY INDUCED DISORDER; CLINICAL PROTOCOL; DIABETIC KETOACIDOSIS; EQUIPMENT; FEMALE; HUMAN; INFUSION PUMP; INSULIN DEPENDENT DIABETES MELLITUS; INSULIN INFUSION; PATIENT EDUCATION;

CLINICAL PROTOCOLS; DIABETES MELLITUS, TYPE 1; DIABETIC KETOACIDOSIS; EQUIPMENT FAILURE; FEMALE; HUMANS; HYPOGLYCEMIC AGENTS; INFUSION PUMPS, IMPLANTABLE; INSULIN; INSULIN INFUSION SYSTEMS; PATIENT EDUCATION;

EID: 33947314308     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/S1553-7250(07)33018-3     Document Type: Article

References (16)

1. Carayon P., et al.: Observing nurse interaction with infusion pump technologies. In Henriksen K., et al. (eds.): Advances in Patient Safety: From Research to Implementation vol. 2. Rockville, MD: Agency for Healthcare Research and Quality, 2005, pp. 349-364. http://www.ahrq.gov/downloads/pub/ advances/vol2/Carayon.pdf (last accessed Jan. 12, 2007).
2. Gosbee L.L.: Theory and general principles. In Gosbee J.W., Gosbee L.L. (eds.): Using Human Factors Engineering to Improve Patient Safety. Oakbrook Terrace, IL: Joint Commission Resources, Inc., 2005, pp. 3-33.
3. The Joint Commission: Sentinel Events. http://www.jointcommission. org/ SentinelEvents/ (last accessed Jan. 10, 2006).
4. Institute of Medicine: To Err is Human: Building a Safer Health System. Washington, D.C: National Academy Press, 1999.
5. Carayon P., et al.: Work system and patient safety. In Luzcak H., Zink K.J. (eds): Human Factors in Organizational Design and Management-VII. Santa Monica, CA: IEA Press, 2003, pp. 583-589.
6. Reason J.: The regulator's unhappy lot. In Reason J. (ed.): Managing the Risks of Organizational Accidents. Aldershot, U.K.: Ashgate, 1997, pp. 157-189.
7. Wilson V.: Clinical guidelines for use of the MS26 daily rate syringe driver in the community. Br J Community Nurs 5: 162-168, Apr. 2000.
8. McConnell E.A., et al.: Australian registered nurse medical device education: A comparison of simple vs. complex devices. J Adv Nurs 23:322-328, Feb. 1996. Erratum in: J Adv Nurs 24:221, Jul. 1996.
9. Gait K.A., et al.: Best practices in medication safety: Areas for improvement in the primary care physician's office. In Henriksen K., et al. (eds.): Advances in Patient Safety: From Research to Implementation vol. 1. Rockville, MD: AHRQ, 2004, pp. 101-129. http://www.ahrq.gov/ downloads/pub/advances/vol1/Galt.pdf (last accessed Jan. 12, 2007).
10. Garmer K., et al.: Arguing for the need of triangulation and iteration when designing medical equipment. J Clin Monit Comput 17:105-114, Feb. 2002.
11. Keselman A., et al.: Institutional decision-making to select patient care devices: Identifying venues to promote patient safety. J Biomed Inform 36:31-44, Feb.-Apr. 2003.
12. Keselman A., et al.: Institutional decision-making for medical device purchasing: Evaluating patient safety. Medinfo 11(Pt 2):1357-1361, 2004.
13. Wetterneck T.B., et al.: Challenges with the performance of Failure Mode and Effects Analysis in healthcare organizations: An IV medication administration HFMEA™. Proceedings of the Annual Conference of the Human Factors and Ergonomics Society. New Orleans, Sep. 21, 2004.
14. Mitchell J.F., et al.: Improving patient safety and reducing risks associated with hydromorphone by using the RCA process. Proceedings of ASHP, Summer Meeting, vol. 60, Jun. 2, 2003.
15. Perry S. J.: An overlooked alliance: Using human factors engineering to reduce patient harm. Jt Comm Qual Saf 30:455-459, Aug. 2004.
16. Grayson D., et al.: Do transient work conditions trigger medical errors? In Henriksen K., et al. (eds.): Advances in Patient Safety: From Research to Implementation vol. 1. Rockville, MD: AHRQ, 2004, pp. 53-64. http://www.ahrq.gov/downloads/pub/advances/vol1/Grayson.pdf (last accessed Jan. 12, 2007).