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.
Free full text
Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.
Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.
Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.
Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.
Origins of and solutions for neonatal medication-dispensing errors.
Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.
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.
View all related resources...
Find Related Resources by...
Setting of Care
Health Care Providers
Quality and Safety Professionals
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
Produced for the
Agency for Healthcare Research and Quality
team of editors
University of California, San Francisco
with guidance from a prominent
. The AHRQ PSNet site was designed and implemented by Silverchair.
Contact AHRQ PSNet
Terms & Conditions
Freedom of Information Act
The White House
USA.gov: U.S. Government Official Web Portal
Agency for Healthcare Research and Quality • 540 Gaither Road Rockville, MD 20850 • Telephone: (301) 427-1364