Commentary ISMP medication error report analysis. Citation Text: Smetzer JL; Cohen MR. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL December 3, 2008 Smetzer JL; Cohen MR. View more articles from the same authors. This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine. Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Smetzer JL; Cohen MR. Copy Citation Related Resources From the Same Author(s) ISMP medication error report analysis. October 29, 2008 ISMP medication error report analysis. December 9, 2009 ISMP medication error report analysis. June 6, 2007 ISMP medication error report analysis. September 26, 2007 ISMP medication error report analysis. January 9, 2008 ISMP medication error report analysis. February 13, 2008 Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. March 6, 2005 ISMP medication error report analysis. January 20, 2010 ISMP medication error report analysis. February 4, 2009 ISMP medication error report analysis. June 4, 2008 ISMP medication error report analysis. April 16, 2008 ISMP medication error report analysis. March 19, 2008 ISMP medication error report analysis. October 28, 2009 ISMP medication error report analysis. June 9, 2010 ISMP medication error report analysis. October 31, 2007 ISMP medication error report analysis. October 7, 2009 ISMP medication error report analysis. April 29, 2009 ISMP medication error report analysis. January 21, 2009 ISMP medication error report analysis. October 1, 2008 ISMP medication error report analysis. September 3, 2008 ISMP medication error report analysis. July 30, 2008 ISMP medication error report analysis. July 9, 2008 ISMP medication error report analysis. March 15, 2006 ISMP medication error report analysis. October 18, 2006 ISMP medication error report analysis. September 13, 2006 ISMP medication error report analysis. December 14, 2005 ISMP medication error report analysis. November 23, 2005 ISMP medication error report analysis. August 8, 2007 ISMP medication error report analysis. June 27, 2007 ISMP medication error report analysis. May 16, 2007 ISMP medication error report analysis. April 25, 2007 ISMP medication error report analysis. September 5, 2007 ISMP medication error report analysis. February 21, 2007 ISMP medication error report analysis. January 17, 2007 ISMP medication error report analysis. July 5, 2006 ISMP medication error report analysis. June 7, 2006 ISMP medication error report analysis. October 26, 2005 ISMP medication error report analysis. August 24, 2005 ISMP medication error report analysis. August 26, 2009 ISMP medication error report analysis. June 24, 2009 ISMP medication error report analysis. May 7, 2008 ISMP medication error report analysis. December 5, 2007 Pediatric safety incidents from an intensive care reporting system. May 27, 2009 Medication Errors. 2nd ed. November 1, 2006 Medical Errors and Patient Safety: A Curriculum Guide for Teaching Medical Students and Family Practice Residents. March 6, 2005 Reducing patient risk from prescription instruction errors—a six sigma approach. June 18, 2008 Shaping systems for better behavioral choices: lessons learned from a fatal medication error. March 24, 2010 The Basics of FMEA. 2nd ed. March 27, 2005 How to avoid falling victim to a hospital mistake. November 25, 2009 Wife 'heartbroken' at death blamed on meningitis. October 24, 2012 Is Grandma drugged up? June 11, 2008 Talking pill bottle aims to curb medical errors. August 17, 2005 The misery of a doctor's first days. October 14, 2015 ISMP medication error report analysis. April 5, 2006 Errors and Malpractice in Radiology. September 26, 2012 When a surgeon should just say 'I'm sorry'. April 6, 2016 Organ donor's surgery death sparks questions. April 18, 2012 Avoiding errors associated with insulin therapy. May 27, 2009 ISMP medication error report analysis. May 27, 2009 Medical research and the Institutional Review Board: the librarian's role in human subject testing. October 26, 2005 Achieving a successful patient safety program with implementation of a harm reduction strategy. October 25, 2023 Serious Safety Events: Getting to Zero. Second Edition. October 17, 2012 Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition. June 1, 2005 Child-specific risk factors and patient safety. May 11, 2005 Assessing patient safety culture in hospital settings. June 2, 2021 Preventing Medication Errors: Quality Chasm Series. July 26, 2006 Perspective: a culture of respect—part 1 and part 2. June 20, 2012 Metric units and the preferred dosing of orally administered liquid medications. April 15, 2015 Transforming the morbidity and mortality conference to promote safety and quality in a PICU. April 6, 2016 Environmental Cleaning for the Prevention of Healthcare-Associated Infections (HAIs). September 16, 2015 Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports. December 16, 2015 Systemic failures in health care oversight. March 20, 2024 Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability. August 16, 2006 Improving medication reconciliation in hospitals. August 31, 2022 Salzburg Global Seminar Session 565—Better Health Care: How Do We Learn About Improvement? May 16, 2018 Knowledge-based information to improve the quality of patient care. February 25, 2009 Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. July 10, 2019 Pediatric medication errors and reduction strategies in the perioperative period. November 24, 2021 Drug shortages: a patient safety crisis. September 7, 2011 Pharmacy Education and Practice. January 26, 2022 Variation in medication information for elderly patients during initial interventions by emergency department physicians. January 16, 2008 Second Annual Nursing Leadership Congress: "Building the Foundation for a Culture of Safety" conference proceedings. June 20, 2007 WebM&M Cases Double Dosing, by the Rules March 21, 2009 Crew resource management training--clinicians' reactions and attitudes. September 28, 2005 WebM&M Cases The 2-Week Itch April 1, 2003 Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center January 15, 2020 When machine learning goes off the rails. A guide to managing the risks. March 3, 2021 Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention. September 21, 2016 Medical errors: where are we now? November 15, 2006 Surgical site infection prevention: a review. February 1, 2023 ACR guidance document on MR safe practices: updates and critical information 2019. August 14, 2019 The successful anesthesia patient safety officer. September 15, 2021 Breast cancer screening and overdiagnosis. August 11, 2021 2008 John M. Eisenberg Patient Safety and Quality Awards. October 8, 2008 Just culture: the foundation of staff safety in the perioperative environment. May 12, 2021 A systematic review of nursing practice workarounds. October 19, 2022 A mixed methods evaluation of medication reconciliation in the primary care setting. March 2, 2022 Nurse sensemaking for responding to patient and family safety concerns. March 17, 2021 Adopting system models for multiple incident analysis: utility and usability. October 27, 2021 Usability and accessibility of publicly available patient safety databases. June 1, 2022 View More Related Resources WebM&M Cases Misconnection Leading to Arterial Thrombosis June 28, 2023 Annual Perspective Improving Diagnostic Safety and Quality April 26, 2023 ISMP Targeted Medication Safety Best Practices for Community Pharmacy. April 19, 2023 Perspectives on Safety Annual Perspective Technology as a Tool for Improving Patient Safety March 29, 2023 ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. November 16, 2022 Annual Perspective Annual Perspective: Topics in Medication Safety March 31, 2022 ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. October 1, 2021 Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. March 17, 2021 FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only. February 3, 2021 Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. November 4, 2020 Perspective Making Healthcare Safer III Report March 30, 2020 Interview In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD March 30, 2020 Annual Perspective Pharmacist Role in Patient Safety February 21, 2020 Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. January 23, 2019 Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention. August 5, 2015 From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. February 26, 2014 Doing right by our patients when things go wrong in the ambulatory setting. February 12, 2014 The effects of electronic prescribing by community-based providers on ambulatory medication safety. December 4, 2013 E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care. October 31, 2012 Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study. May 16, 2012 Ambulatory prescribing errors among community-based providers in two states. December 21, 2011 Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. March 23, 2011 Pharmacy mixes up prescriptions. February 16, 2011 Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. February 9, 2011 Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. July 28, 2010 ISMP medication error report analysis. June 9, 2010 ISMP medication error report analysis. May 12, 2010 ISMP medication error report analysis. April 21, 2010 WebM&M Cases Bad Writing, Wrong Medication April 1, 2010 ISMP medication error report analysis. March 10, 2010 View More See More About The Topic Hospitals Ambulatory Care Health Care Providers Risk Managers Anesthesiology View More
Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. March 6, 2005
Medical Errors and Patient Safety: A Curriculum Guide for Teaching Medical Students and Family Practice Residents. March 6, 2005
Shaping systems for better behavioral choices: lessons learned from a fatal medication error. March 24, 2010
Medical research and the Institutional Review Board: the librarian's role in human subject testing. October 26, 2005
Achieving a successful patient safety program with implementation of a harm reduction strategy. October 25, 2023
Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition. June 1, 2005
Transforming the morbidity and mortality conference to promote safety and quality in a PICU. April 6, 2016
Environmental Cleaning for the Prevention of Healthcare-Associated Infections (HAIs). September 16, 2015
Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports. December 16, 2015
Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability. August 16, 2006
Salzburg Global Seminar Session 565—Better Health Care: How Do We Learn About Improvement? May 16, 2018
Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. July 10, 2019
Variation in medication information for elderly patients during initial interventions by emergency department physicians. January 16, 2008
Second Annual Nursing Leadership Congress: "Building the Foundation for a Culture of Safety" conference proceedings. June 20, 2007
Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center January 15, 2020
Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention. September 21, 2016
Perspectives on Safety Annual Perspective Technology as a Tool for Improving Patient Safety March 29, 2023
Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. March 17, 2021
FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only. February 3, 2021
Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. November 4, 2020
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. January 23, 2019
Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention. August 5, 2015
From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. February 26, 2014
The effects of electronic prescribing by community-based providers on ambulatory medication safety. December 4, 2013
E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care. October 31, 2012
Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study. May 16, 2012
Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. March 23, 2011
Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. February 9, 2011
Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. July 28, 2010