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Caution, Interrupted.
Wears RL. AHRQ WebM&M [serial online]. September 2004.
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and hangs the bag anyway.
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Resource Type
Commentary
Setting of Care
Emergency Departments
Target Audience
Health Care Providers
Organizational Behaviorists
Safety Scientists
Clinical Area
Emergency Medicine
Emergency Nursing
Hospital Pharmacy
Safety Target
Discontinuities, Gaps, and Hand-Off Problems
Dispensing Errors
Administration Errors
Look-Alike, Sound-Alike Drugs
Error Types
Noncognitive Errors ("Slips & Lapses")
Near Miss
Approach to Improving Safety
Root Cause Analysis
Communication between Providers
Logistical Approaches
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)