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Engineers
PATIENT SAFETY PRIMERS
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Device-related Complications (63)
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STUDY
Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.
Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. JAMA. 2010;304:2595-2602.
NEWSPAPER/MAGAZINE ARTICLE
ALERT: reports of severe harm after intravenous administration of breast milk to infants.
ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.
NEWSPAPER/MAGAZINE ARTICLE
Medication errors: a year in review.
Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.
PRESS RELEASE/ANNOUNCEMENT
Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010.
Rockville, MD: US Food and Drug Administration; November 9, 2010.
COMMENTARY
Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.
Turakhia MP, Estes NA 3rd, Drew BJ, et al; Electrocardiography and Arrhythmias Committee of the American Heart Association Council on Clinical Cardiology and Council on Cardiovascular Nursing. Circulation. 2012;126:1665-1669.
STUDY
Management of anesthesia equipment failure: a simulation-based resident skill assessment.
Waldrop WB, Murray DJ, Boulet JR, Kras JF. Anesth Analg. 2009;109:426-433.
COMMENTARY
MRI suites: safety outside the bore.
Gilk T. Patient Saf Qual Healthc. September/October 2006;3:16-18, 20-21.
NEWSPAPER/MAGAZINE ARTICLE
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
ISMP Medication Safety Alert! April 8, 2010;15:1-3.
NEWSPAPER/MAGAZINE ARTICLE
Pharmaceutical industry and medical device companies: part of the solution?
ISMP Medication Safety Alert! Acute Care Edition. November 16, 2006;11:1, 3.
STUDY
Effect of computerized physician order entry on radiologic examination order indication quality.
Schneider E, Franz W, Spitznagel R, Bascom DA, Obuchowski NA. Arch Intern Med. 2011;171:1036-1038.
ORGANIZATIONAL POLICY/GUIDELINES
Radiation risks of diagnostic imaging.
Sentinel Event Alert #47. August 24, 2011.
REVIEW
Enteral feeding misconnections: an update.
Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-334.
REVIEW
Tubing misconnections: normalization of deviance.
Simmons D, Symes L, Guenter P, Graves K. Nutr Clin Pract. 2011;26:286-293.
COMMENTARY
Enteral feeding misconnections: a consortium position statement.
Guenter P, Hicks RW, Simmons D, et al. Jt Comm J Qual Patient Saf. 2008;34:285-292.
STUDY
Novel analysis of clinically relevant diagnostic errors in point-of-care devices.
Shermock KM, Streiff MB, Pinto BL, Kraus P, Pronovost PJ. J Thromb Haemost. 2011;9:1769-1775.
STUDY
Impact of a comprehensive safety initiative on patient-controlled analgesia errors.
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
ORGANIZATIONAL POLICY/GUIDELINES
Medical device alarm safety in hospitals.
Sentinel Event Alert. April 8, 2013;(50):1-3.
ORGANIZATIONAL POLICY/GUIDELINES
Preventing maternal death.
Sentinel Event Alert. January 26, 2010;(44):1-4.
COMMENTARY
Lethal Cap.
Schillinger D. AHRQ WebM&M [serial online]. March 2004.
COMMENTARY
Risks related to patient bed safety.
Sharkey JE, Van Leuven K, Radovich P. J Nurs Care Qual. 2012;27:346-351.
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