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Vial Mistakes Involving Heparin.
Vanderveen T. AHRQ WebM&M [serial online]. May 2009.
Hospitalized for an elective procedure, a patient is given heparin in an incorrect concentration—off by a factor of 100.
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COMMENTARY
The Role of Bar Coding and Smart Pumps in Safety
Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN AHRQ WebM&M [serial online]. September 2008.
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Resource Type
Commentary
Setting of Care
Operating Room
Target Audience
Health Care Providers
Quality and Safety Professionals
Clinical Area
Anesthesiology
Hospital Pharmacy
Vascular Surgery
Safety Target
Infusion Pumps
Dispensing Errors
Anticoagulants
Surgical Complications
Error Types
Epidemiology of Errors and Adverse Events
Approach to Improving Safety
Human Factors Engineering
Clinical Pharmacist Involvement
Automatic drug dispensers
Bar Coding and Radiofrequency ID Tagging
Clinical Information Systems