AHRQ Patient Safety Network

The Collection > Medical Device Design

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Safety Target

•Device-related Complications (76)

•Diagnostic Errors (6)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (2)

•Medication Safety (49)

•Medical Complications (9)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (8)

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•Africa (1)

•Asia (2)

•Australia and New Zealand (3)

•Central and South America (1)

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•Journal Article (72)

•Legislation/Regulation (4)

•Newspaper/Magazine Article (24)

•Press Release/Announcement (5)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (15)

•Active Errors (34)

•Latent Errors (21)

•Near Miss (2)

Approach to Improving Safety
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Medical Device Design

Clinical Areas

•Allied Health Services (3)

•Medicine (64)

•Nursing (13)

•Pharmacy (17)

Target Audience

•Health Care Providers (78)

•Health Care Executives and Administrators (76)

•Non-Health Care Professionals (73)

•Patients (13)

Setting of Care

•Hospitals (57)

•Residential Facilities (2)

•Ambulatory Care (7)

•Outpatient Surgery (1)

1 - 20 of 115

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STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

AUDIOVISUAL

Safety Information on Alaris SE Infusion Pumps.

Food and Drug Administration (FDA) Patient Safety News. Show #57. November 2006.

STUDY

Applying a multidisciplinary approach to the selection, evaluation, and acquisition of smart infusion pumps.

Namshirin P, Ibey A, Lamsdale A. J Med Bio Eng. 2011;31:93-98.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

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.

PRESS RELEASE/ANNOUNCEMENT

United States marshals seize defective infusion pumps made by Alaris Products.

Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; August 29, 2006.

STUDY

Enhancing patient safety with intelligent intravenous infusion devices: experience in a specialty cardiac hospital.

Wood JL, Burnette JS. Heart Lung. 2012;41:173-176.

STUDY

Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety.

Porat N, Bitan Y, Shefi D, Donchin Y, Rozenbaum H. Qual Saf Health Care. 2009;18:505-509.

COMMENTARY

Taking aim at infusion confusion.

Burdeu G, Crawford R, van de Vreede M, McCann J. J Nurs Care Qual. 2006;21:151-159.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

STUDY

Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency.

Thomas AN, Galvin I. Anaesthesia. 2008;63:1193-1197.

REVIEW

Enteral feeding misconnections: an update.

Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-334.

STUDY

An engineered solution to the maladministration of spinal injections.

Lawton R, Gardner P, Green B, et al. Qual Saf Health Care. 2009;18:492-495.

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

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

STUDY

Do split-side rails present an increased risk to patient safety?

Hignett S, Griffiths P. Qual Saf Health Care. 2005;14:113-116.

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.

COMMENTARY

The Wild West: Patient Safety in Office-Based Anesthesia

Kaushal R, Upadhyayula S, Gaba DM, Leape LL. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].

Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.

NEWSPAPER/MAGAZINE ARTICLE

Double key bounce and double keying errors.

ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.

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