External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.
Fluorouracil Incident Root Cause Analysis Report.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. May 8, 2007.
Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.
Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.
ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.
Failure to Report
Spath PL. AHRQ WebM&M [serial online]. March 2007.
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