Debora Simmons

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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)
In a neonatal unit, an experienced nurse inadvertently connected a feeding tube to an intravenous catheter. An analysis of this error, including the historical perspective, reveals that this threat to safety has been documented since 1972. Implications for nursing practice include the redesign of systems to accommodate human factors science and a change in(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)
Enteral misconnections are defined as inadvertent connections between enteral feeding systems and nonenteral systems such as intravascular lines, peritoneal dialysis catheters, tracheostomy tube cuffs, medical gas tubing, and so on. Sentinel event data and causative factors are outlined along with potential solutions to prevent such medical errors. The(More)