Near-infrared spectroscopy monitors: a novel tool for patient safety in the intensive care unit.
Medication errors due to adverse incidents with medical devices are a significant contributor to the total number of hospital errors. Unfortunately, there may be no warning when a device fails, and caregivers may not have an opportunity to prevent patient harm as a result. An error of unrecognized interruption of infusions of cardiac medications can cause rapid patient deterioration. In the case presented, near-infrared spectroscopy monitoring alerted caregivers to an otherwise clinically silent error with infused cardiac medications in the intensive care unit and permitted recognition and intervention before patient harm occurred.
Kane
Jason M
JM
Department of Pediatrics, Section of Critical Care/Medicine/Cardiac Intensive Care, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL 60614, USA. jkane@childrensmemorial.org
D004059:Diffusion of Innovation; D016503:Drug Delivery Systems; D004868:Equipment Failure; D006801:Humans; D000860:Hypoxia / Q000175:diagnosis; D015278:Intensive Care Units, Pediatric; D008508:Medication Errors / Q000517:prevention & control*; D017751:Safety Management; D019265:Spectroscopy, Near-Infrared / Q000295:instrumentation*