Newspaper/Magazine Article Fatal drug mix-up exposes hospital flaws. Citation Text: Davies T. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL September 27, 2006 Davies T. View more articles from the same authors. This article reports on the deaths of three infants from heparin overdoses and describes how the hospital community has responded to the errors. Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Davies T. Copy Citation Related Resources From the Same Author(s) Effective Board Governance of Safe Care: A (Theoretically Underpinned) Cross-sectioned Examination of the Breadth and Depth of Relationships through National Quantitative Surveys and In-depth Qualitative Case Studies. March 2, 2016 Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. 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Effective Board Governance of Safe Care: A (Theoretically Underpinned) Cross-sectioned Examination of the Breadth and Depth of Relationships through National Quantitative Surveys and In-depth Qualitative Case Studies. March 2, 2016
Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety. October 11, 2017
Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. October 5, 2022
Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey. March 22, 2023
Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings. December 7, 2022
Use of administrative data to find substandard care: validation of the complications screening program. October 26, 2005
Alarm management: first things first: using reliable data to eliminate unnecessary alarms. December 10, 2014
Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.' January 28, 2015
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data. May 11, 2005
Preventing lawsuits: Coalition pushes apologies and cash up-front. Dealing with medical errors when they happen--instead of in court--can benefit doctors and patients, supporters say. March 27, 2005
Information Design for Patient Safety: A Guide to the Graphic Design of Medication Packaging. 2nd edition. November 23, 2007
The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety. January 14, 2015
Active learning: when is more better? The case of resident physicians' medical errors. October 14, 2009
Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report. November 21, 2018
You can't understand something you hide: transparency as a path to improve patient safety. July 8, 2015
Nursing Home Survey on Patient Safety Culture: 2011 User Comparative Database Report. September 14, 2011
AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative Database Report. November 23, 2016
AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative Database Report. November 19, 2014
Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. July 11, 2007
Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary Report. November 17, 2010
2012 User Comparative Database Report: Medical Office Survey on Patient Safety Culture. June 27, 2012
Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report. July 22, 2015
AHRQ Nursing Home Survey on Patient Safety Culture: 2019 User Comparative Database Report. February 20, 2019
Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative Database Report. April 17, 2019
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study. January 6, 2010
Medical Office Survey on Patient Safety Culture: 2014 User Comparative Database Report. June 25, 2014
Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study. May 16, 2012
Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review. April 20, 2022
Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report. April 6, 2022
Leveraging a safety event management system to improve organizational learning and safety culture. March 30, 2022
When no news is bad news: improving diagnostic testing communication through patient engagement. March 9, 2022
Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study. March 2, 2022
Latent safety threats and countermeasures in the operating theater: a national in situ simulation-based observational study. February 23, 2022
Nursing guidelines for comprehensive harm prevention strategies for adult patients in acute hospitals: an integrative review and synthesis. February 23, 2022
Adverse events during intrahospital transport of critically ill patients: a systematic review and meta-analysis. February 9, 2022
Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study. August 10, 2022
Improving shared situation awareness for high-risk therapies in hospitalized children. January 19, 2022
Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis. January 19, 2022
A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad. January 12, 2022
The impact of health information management professionals on patient safety: a systematic review. December 22, 2021
Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach. February 21, 2024
Nurses' perception of medication administration errors and factors associated with their reporting in the neonatal intensive care unit. January 17, 2024
Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis. December 14, 2022
Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care. October 5, 2022
Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. April 13, 2022
Start the year off right by addressing these top 10 medication safety concerns from 2021. February 9, 2022
Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020
Impact of interoperability of smart infusion pumps and an electronic medical record in critical care. September 23, 2020
Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. March 11, 2020
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems. September 4, 2019
Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit. August 28, 2019
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. January 23, 2019
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. October 17, 2018
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. November 5, 2014
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit. October 8, 2014
Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams. July 24, 2013
Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections. June 5, 2013
Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project. November 21, 2012
Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system. January 26, 2011