Pape T. AHRQ WebM&M [serial online]. Febuary 2006.
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
Free full text
Wrong Route for Nutrients
Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.
A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.
Waltham, MA: Masspro, Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Foundation; 2007.
Nursing home error and level of staff credentials.
Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.
Cups of Error
Blegen MA, Pepper GA. AHRQ WebM&M [serial online]. May 2006.
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Setting of Care
Facility and Group Administrators
Discontinuities, Gaps, and Hand-Off Problems
Look-Alike, Sound-Alike Drugs
Noncognitive Errors ("Slips & Lapses")
Approach to Improving Safety
Human Factors Engineering
Nurse Staffing Ratios
Automatic drug dispensers
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