Categories
Thumbnail associated with Event Reporting story titled: Buttoning Up a System
Buttoning Up a System
Electronic Health Record
Communication
Medication
While changing the directions for insulin, a nurse identified that the “No Print” button in her hospital’s electronic medical record (EMR) was sending a prescription (Rx) cancellation to the pharmacy.
Thumbnail associated with Event Reporting story titled: Code Blood Bank
Code Blood Bank
Emergency Department
Communication
Lab
In response to an emergent blood transfusion scenario, emergency department (ED) staff followed policy and contacted the blood bank to start the unmatched blood acquisition process in case rapid transfusion was needed. However, once the order was received, the blood bank encountered several barriers to complete the request.
Thumbnail associated with Event Reporting story titled: Standardizing Patient Wristband Colors
Standardizing Patient Wristband Colors
Communication
About a decade ago, a patient almost died when a traveling nurse mistakenly gave him a wristband indicating “do not resuscitate,” thinking it meant something else.
Thumbnail associated with Event Reporting story titled: Improving Reporting Practices With Tiered Huddles
Improving Reporting Practices With Tiered Huddles
Communication
Event reporting is most effective if everyone knows what should be reported, there are no barriers to reporting, staff is encouraged to report, and there is proper escalation and follow-up from leadership on reported events.
Thumbnail associated with Event Reporting story titled: Challenges in Patient Hand-Offs Between Hospitals
Challenges in Patient Hand-Offs Between Hospitals
Communication
Medication
A patient with acute thrombus—a blood clot in a vein or artery—was being transferred from an emergency department at a small outlying facility (“transferring facility”) to the intensive care unit (ICU) at a larger hospital (“receiving facility”).