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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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NEWSPAPER/MAGAZINE ARTICLE
Another tragic parenteral nutrition compounding error.
ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
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Resource Type
Newspaper/Magazine Article
Setting of Care
Children’s Hospitals
Target Audience
Nurses
Pharmacists
Quality and Safety Professionals
Clinical Area
Critical Care
Neonatology and Intensive Care
Hospital Pharmacy
Safety Target
Infusion Pumps
Dispensing Errors
Error Types
Active Errors
Approach to Improving Safety
Failure Mode Effects Analysis
Communication between Providers
Human Factors Engineering
Logistical Approaches
Culture of Safety
Automatic drug dispensers
Education and Training
Origin/Sponsor
United States of America