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On July 4, 2008, in one of the more tragic medical accidents in recent memory, 14 babies in the ICU at Christus Spohn Hospital South in Corpus Christi, TX, received doses of Heparin that were 100 times stronger than the recommended doses, according to the Associated Press (AP). Two of the babies died, reported the AP, which also said the hospital blamed a "mixing error" in the pharmacy.
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"We consistently see the need to document things" she says. "For example, when a caregiver communicates in the hospital during a handoff and points out to the next caregivers the updated, reconciled medication list, they are supposed to document that they did it.
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Citing scientific research that shows a direct link between "intimidating and disruptive behaviors" on the part of health care providers and adverse outcomes, The Joint Commission has both issued a Sentinel Event Alert and unveiled a new leadership standard effective Jan. 1, 2009, to encourage hospitals to identify and deal with such behaviors.
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Violence in the emergency department (ED) is such a common occurrence that staff can become complacent about the risks they face daily.
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Angry, violent individuals need specialized attention, and improperly handling a crisis can mean years of litigation, warns Robert Siciliano, CEO of NurseSecurity.com and a personal security expert in Boston.
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The national focus on patient-centered care isn't just about teaching patients to become more engaged in self-management of their careit also means putting patients on committees and advisory boards to participate in the process of developing quality programs.
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A growing number of organizations are disclosing errors to patients, but this can be disastrous if handled poorly.
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Pharmacy leaders across the United States have created a model that makes it easier for hospital pharmacies to create a high-performance pharmacy practice within their own institutions.
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Since evidence-based prescribing practices and consistency in a health care setting can lead to better quality and safety outcomes, the key is in developing a strategy for achieving these goals.
