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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Forster A. AHRQ WebM&M [serial online]. December 2004.
XL or Smaller?
Kozer E. AHRQ WebM&M [serial online]. June 2003.
Adams JG. AHRQ WebM&M [serial online]. June 2003.
The Dropped Lung.
Heffner JE. AHRQ WebM&M [serial online]. May 2003.
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Setting of Care
Health Care Providers
Discontinuities, Gaps, and Hand-Off Problems
Look-Alike, Sound-Alike Drugs
Noncognitive Errors ("Slips & Lapses")
Approach to Improving Safety
Root Cause Analysis
Communication between Providers
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