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Medical Device Design
PATIENT SAFETY PRIMERS
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AUDIOVISUAL
Talking pill bottle aims to curb medical errors.
Cohen B. "Morning Edition." National Public Radio. August 1, 2005.
COMMENTARY
Improving safety throughout the medication use process in a neonatal intensive care unit.
Asdigha MN. Hosp Pharm. 2006;41:1067-1075.
NEWSPAPER/MAGAZINE ARTICLE
IV potassium given epidurally: getting to the "route" of the problem.
ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.
COMMENTARY
Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.
Keohane CA, Hayes J, Saniuk C, Rothschild JM, Bates DW. J Infus Nurs. 2005;28:321-328.
ORGANIZATIONAL POLICY/GUIDELINES
Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag.
Information Exchange System Alert. Geneva, Switzerland: World Health Organization; July 18, 2007.
STUDY
Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.
Maragakis LL, Bradley KL, Song X, et al. Infect Control Hosp Epidemiol. 2006;27:67-70.
COMMENTARY
Automated dispensing cabinets.
Gaunt MJ, Johnston J, Davis MM. Am J Nurs. 2007;107:27-28.
NEWSPAPER/MAGAZINE ARTICLE
Double key bounce and double keying errors.
ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.
COMMENTARY
Thin Air.
Gaba DM. AHRQ WebM&M [serial online]. October 2004.
NEWSPAPER/MAGAZINE ARTICLE
Target pill bottles now convenient and cute.
Bull G. USA Today. April 28, 2005.
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
Epidural-IV route mix-ups: reducing the risk of deadly errors.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
NEWSPAPER/MAGAZINE ARTICLE
An extra dose of safety.
Health Manage Techol. April 2007;28:30-32, 34.
STUDY
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.
Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.
ORGANIZATIONAL POLICY/GUIDELINES
Tubing misconnections—a persistent and potentially deadly occurrence.
Sentinel Event Alert. April 3, 2006;(36):1-3.
STUDY
Increasing vigilance on the medical/surgical floor to improve patient safety.
Jacobs JL, Apatov N, Glei M. J Adv Nurs. 2007;57:472-481.
COMMENTARY
New technology, new errors: how to prime an upgrade of an insulin infusion pump.
Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.
NEWSPAPER/MAGAZINE ARTICLE
M.R.I.'s strong magnets cited in accidents.
McNeil DG Jr. New York Times. August 19, 2005;National Desk section:1.
COMMENTARY
Hidden Mystery.
Brunette DD. AHRQ WebM&M [serial online]. March 2005.
NEWSPAPER/MAGAZINE ARTICLE
Fatal gas line mix-up: How to avoid making this "gastly" mistake.
ISMP Medication Safety Alert! Acute Care Edition. December 16, 2004;9:1-2.
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