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BACKGROUND Accidental connection of an enteral system to an intravenous (IV) system frequently results in the death of the patient. Misconnections are commonly attributed to the presence of universal connectors found in the majority of patient care tubing systems. Universal connectors allow for tubing misconnections between physiologically incompatible(More)
Teamwork is considered a critical factor in delivering high-quality, safe patient care although research on the evidence base of the effectiveness of teamwork and communication across disciplines is scarce. Health care providers have limited educational preparation for the communication and complex care coordination across disciplines required by today's(More)
The safety of patients receiving sedation and sedating analgesia therapies is a system property. There are multiple team members and processes needed to ensure safety that reside outside the purview of nursing. This article outlines safety considerations in sedation using the Eindhoven classification system as framework for aggregating contributing factors(More)
A growing body of scientific evidence demonstrates negative effects of fatigue on human performance. Nursing practice encompasses many tasks that require optimal performance. Fatigue can be the result of a multitude of contributing causes. Nurses and nursing leaders must be aware of the causes and effects of fatigue and ensure that its impact is considered(More)
ii Acknowledgments The authors gratefully acknowledge the intellectual contributions from the following reviewers: iii DISCLAIMER Certain commercial entities, equipment, or material may be identified in this document in order to describe a concept adequately. Such identification is not intended to imply recommendation or endorsement by the National(More)
This report describes the development and implementation of The University of Texas Close Call Reporting System, an anonymous tool used to collect information about potential errors that do not reach the patient. The system was originally developed through experimentation, using a fund of knowledge collected in the aviation industry. A multidisciplinary(More)
In addition, the authors appreciate the access to the data collected under NIST contract number SB134110CN0107 (UL-Wiklund) and the many instructive contributions from a broad spectrum of stakeholders on the draft document during an invited stakeholder meeting held at the National Institute of Standards and Technology on September 28, 2015, as well as peer(More)