Don't underestimate the impact of change on risk potential.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.
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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.
Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies.
Holden RJ, Patel NR, Scanlon MC, Shalaby TM, Arnold JM, Karsh BT. Res Social Admin Pharm. 2010;6:293-306.
ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.
Another tragic parenteral nutrition compounding error.
ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
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