Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial.

Background: Incident reporting is widely used in hospitals to improve patient safety, but current reporting systems do not function optimally. The utility of incident reports is limited because hospital staff may not know what to report, may fear retaliation, and may doubt whether administrators will review reports and respond effectively. Methods: This is a clustered randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. The SAFE Loop has six key attributes: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will focus on medication errors and randomize 20 nursing units at a large academic/community hospital in Los Angeles. Outcomes include: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. Quantitative analyses will compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses will explore nurses' experiences with implementation. Conclusion: If effective, SAFE Loop will have several benefits: increasing nurses' engagement with reporting, producing more informative reports, enabling safety leaders to understand problems, designing system-based solutions more effectively, and lowering rates of high-priority patient safety events.

Hardwiring Safety Into the Computer System: One Hospital's Actions to Provide Technology Support for U-500 Insulin.

We present technology enhancements that support the safe use of U-500 insulin.

Chloral Hydrate: Is It Still Being Used? Are There Safer Alternatives?

Using chloral hydrate carries a risk of adverse events and compounding errors, and much of the available literature recommends using alternative sedatives for pediatric patients. But evidence regarding the efficacy of chloral hydrate and of alternative agents is conflicting.

Accidental IV Infusion of Heparinized Irrigation in the Operating Room.

Accidental IV administration of heparinized irrigation solution occurs frequently. Two cases from ISMP Canada offer some safe practice recommendations.

Understanding Human Over-Reliance On Technology.

Implementing IT in medication-use systems reduces adverse drug events by decreasing human error. But over-reliance on technology can lead to automation bias and complacency.

Is an Indication-Based Prescribing System in Our Future?

Indication-based prescribing has many potential benefits, including preventing errors by reducing medication choices and assisting with medication reconciliation.

"Use as Directed" Can Cause Confusion for Both Patients and Practitioners.

The familiar but ambiguous sigs on prescriptions are often of limited help to patients and pharmacists. Sometimes, the instruction to "use as directed" has resulted in serious errors.

Paralyzed by Mistakes - Reassess the Safety of Neuromuscular Blockers in Your Facility.

Neuromuscular blockers have been inadvertently administered to patients who were not receiving proper ventilatory assistance, causing death or permanent injuries.

Prescribing Errors with Levetiracetam Oral Solution.

Incorrectly prescribed medications can have serious implications, especially in young children. Safe practice recommendations include listing patients' age, weight, and date of birth on prescriptions, verifying discharge orders, and involving pharmacists in reconciliation.

Partially Filled Vials and Syringes in Sharps Containers Are a Key Source of Drug Diversion.

Leftover or improperly discarded drugs are easy prey for diversion and are fueling the opioid abuse epidemic. ISMP offers safe practice recommendations to prevent drug misuse.

Selected Medication Safety Risks That Can Easily Fall Off the Radar Screen-Part 3.

The final part of a 3-part series discusses medication safety risks related to labeling, patient education, and medication storage.

Selected Medication Safety Risks That Can Easily Fall Off the Radar Screen-Part 2.

Part 2 of a 3-part series discusses medication safety risks related to labeling, patient education, and medication storage.

Selected Medication Safety Risks That Can Easily Fall Off the Radar Screen.

Part 1 of a 3-part series discusses 3 medication safety risks that can easily fall off the radar screen in hospitals and doctors' offices.

Ambulatory Pump Safety: Managing Home Infusion Patients Admitted to The Emergency Department and Hospital.

Managing home infusion patients in the hospital and emergency department.

A Successful ENFit Launch Still Won't Stop All Incidents of Oral Medications Given Intravenously.

Preventing incidents of oral meds given intravenously.

Accidental Overdoses Involving Fluorouracil Infusions.

Accidental overdoses involving fluorouracil infusions.

Life-Threatening Errors With Flecainide Suspension in Children.

Errors with flecainide suspension in children.

Severe Harm and Death Associated With Errors and Drug Interactions Involving Low-Dose Methotrexate.

Harm and death associated with methotrexate errors.

Key Vulnerabilities in the Surgical Environment: Container Mix-Ups And Syringe Swaps.

Container mix-ups and syringe swaps in the surgical environment.

The Absence of a Drug-Disease Interaction Alert Leads to a Child's Death.

The absence of a drug-disease interaction alert leads to a child's death.