Newspaper/Magazine Article Fatal drug mix-up exposes hospital flaws. Citation Text: Davies T. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL September 27, 2006 Davies T. View more articles from the same authors. This article reports on the deaths of three infants from heparin overdoses and describes how the hospital community has responded to the errors. Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Davies T. Copy Citation Related Resources From the Same Author(s) Effective Board Governance of Safe Care: A (Theoretically Underpinned) Cross-sectioned Examination of the Breadth and Depth of Relationships through National Quantitative Surveys and In-depth Qualitative Case Studies. March 2, 2016 Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. 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Effective Board Governance of Safe Care: A (Theoretically Underpinned) Cross-sectioned Examination of the Breadth and Depth of Relationships through National Quantitative Surveys and In-depth Qualitative Case Studies. March 2, 2016
Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017
Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.' January 28, 2015
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data. May 11, 2005
Preventing lawsuits: Coalition pushes apologies and cash up-front. Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients, supporters say. March 27, 2005
Alarm management: first things first: using reliable data to eliminate unnecessary alarms. December 10, 2014
Use of administrative data to find substandard care: validation of the complications screening program. October 26, 2005
Doctors' perceived working conditions and the quality of patient care: a systematic review. July 17, 2019
Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. November 11, 2020
Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. November 1, 2023
Health Care Opinion Leaders' Views on the Quality and Safety of Health Care in the United States. August 15, 2007
Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. October 5, 2022
Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens. April 12, 2006
Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience. July 10, 2019
Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings. January 10, 2018
Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy. February 5, 2020
Business Intelligence dashboards for patient safety and quality: a narrative literature review. June 22, 2022
Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews. September 19, 2018
Tiered daily huddles: the power of teamwork in managing large healthcare organisations. October 7, 2020
Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1). May 5, 2021
Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse. September 8, 2021
Bringing change-of-shift report to the bedside: a patient- and family-centered approach. December 1, 2010
How and when organization identification promotes safety voice among healthcare professionals. October 6, 2021
Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings. December 7, 2022
Description and factors associated with missed nursing care in an acute care community hospital. October 17, 2018
A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality. October 20, 2021
Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. October 31, 2007
Perspectives on patient and family engagement with reduction in harm: the forgotten voice. August 15, 2018
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Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. August 10, 2011
Information Design for Patient Safety: A Guide to the Graphic Design of Medication Packaging. 2nd edition. November 23, 2007
Bias at warp speed: how AI may contribute to the disparities gap in the time of COVID-19. September 9, 2020
Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey. March 22, 2023
Impact of SARS-CoV-2 on hospital acquired infection rates in the United States: predictions and early results. November 25, 2020
Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study. April 19, 2017
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Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis. December 14, 2022
Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. April 13, 2022
Start the year off right by addressing these top 10 medication safety concerns from 2021. February 9, 2022
Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020
Impact of interoperability of smart infusion pumps and an electronic medical record in critical care. September 23, 2020
Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. March 11, 2020
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems. September 4, 2019
Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit. August 28, 2019
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. January 23, 2019
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. October 17, 2018
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. November 5, 2014
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit. October 8, 2014
Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams. July 24, 2013
Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections. June 5, 2013
Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project. November 21, 2012
Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system. January 26, 2011