ISMP medication error report analysis. | PSNet

Provide Feedback |

Submit a Case

Register

Commentary

ISMP medication error report analysis.

February 4, 2009

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.

View more articles from the same authors.

This monthly selection of medication error reports includes information about the risks of cutting medication patches, describes examples of drug name confusion, and explains the importance of indicating the purpose for the medication on prescriptions.

Related Resources From the Same Author(s)

ISMP medication error report analysis.

January 20, 2010

ISMP medication error report analysis.

October 28, 2009

ISMP medication error report analysis.

April 16, 2008

ISMP medication error report analysis.

June 4, 2008

ISMP medication error report analysis.

March 19, 2008

ISMP medication error report analysis.

October 31, 2007

ISMP medication error report analysis.

June 9, 2010

ISMP medication error report analysis.

October 29, 2008

Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals.

March 6, 2005

ISMP medication error report analysis.

December 9, 2009

ISMP medication error report analysis.

February 13, 2008

ISMP medication error report analysis.

January 9, 2008

ISMP medication error report analysis.

September 26, 2007

ISMP medication error report analysis.

June 6, 2007

ISMP medication error report analysis.

December 3, 2008

ISMP medication error report analysis.

June 24, 2009

ISMP medication error report analysis.

August 26, 2009

ISMP medication error report analysis.

May 7, 2008

ISMP medication error report analysis.

December 5, 2007

ISMP medication error report analysis.

May 27, 2009

ISMP medication error report analysis.

April 29, 2009

ISMP medication error report analysis.

January 21, 2009

ISMP medication error report analysis.

October 7, 2009

ISMP medication error report analysis.

October 1, 2008

ISMP medication error report analysis.

September 3, 2008

ISMP medication error report analysis.

July 30, 2008

ISMP medication error report analysis.

July 9, 2008

ISMP medication error report analysis.

March 15, 2006

ISMP medication error report analysis.

December 14, 2005

ISMP medication error report analysis.

October 18, 2006

ISMP medication error report analysis.

February 21, 2007

ISMP medication error report analysis.

January 17, 2007

ISMP medication error report analysis.

September 5, 2007

ISMP medication error report analysis.

August 8, 2007

ISMP medication error report analysis.

September 13, 2006

ISMP medication error report analysis.

July 5, 2006

ISMP medication error report analysis.

June 7, 2006

ISMP medication error report analysis.

November 23, 2005

ISMP medication error report analysis.

October 26, 2005

ISMP medication error report analysis.

May 16, 2007

ISMP medication error report analysis.

April 25, 2007

ISMP medication error report analysis.

June 27, 2007

ISMP medication error report analysis.

August 24, 2005

The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference.

March 4, 2009

Medication Errors. 2nd ed.

November 1, 2006

Implementing a bar-code medication administration system.

January 21, 2009

Pediatric safety incidents from an intensive care reporting system.

May 27, 2009

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

October 15, 2008

Developing a medication patient safety program, part 2: process and implementation.

April 25, 2007

Health literacy, medication errors, and health outcomes: is there a relationship?

July 5, 2006

The problems of detecting medication errors in hospitals.

March 6, 2005

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

March 24, 2010

The Safety of Intravenous Drug Delivery Systems: Update on Current Issues Since the 2009 Consensus Development Conference.

September 5, 2018

Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times.

September 14, 2022

Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets.

February 3, 2021

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.

March 29, 2023

Criteria for the selection of paediatric patients susceptible to reconciliation error.

November 16, 2022

Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices.

August 24, 2022

Wife 'heartbroken' at death blamed on meningitis.

October 24, 2012

How to avoid falling victim to a hospital mistake.

November 25, 2009

Is Grandma drugged up?

June 11, 2008

Talking pill bottle aims to curb medical errors.

August 17, 2005

The misery of a doctor's first days.

October 14, 2015

ISMP medication error report analysis.

April 5, 2006

Organ donor's surgery death sparks questions.

April 18, 2012

When a surgeon should just say 'I'm sorry'.

April 6, 2016

Medical Errors and Patient Safety: A Curriculum Guide for Teaching Medical Students and Family Practice Residents.

March 6, 2005

Medical research and the Institutional Review Board: the librarian's role in human subject testing.

October 26, 2005

Avoiding errors associated with insulin therapy.

May 27, 2009

Reducing patient risk from prescription instruction errors—a six sigma approach.

June 18, 2008

Serious Safety Events: Getting to Zero. Second Edition.

October 17, 2012

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition.

June 1, 2005

The Basics of FMEA. 2nd ed.

March 27, 2005

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting.

March 3, 2021

Child-specific risk factors and patient safety.

May 11, 2005

Perspective: a culture of respect—part 1 and part 2.

June 20, 2012

Preventing Medication Errors: Quality Chasm Series.

July 26, 2006

Avoiding a Med-Wreck: a structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources.

March 3, 2021

Metric units and the preferred dosing of orally administered liquid medications.

April 15, 2015

Perceptions of working conditions and safety concerns in community pharmacy.

September 8, 2021

Reducing errors through discharge medication reconciliation by pharmacy services.

August 26, 2015

How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety?

December 7, 2022

A qualitative exploration of the impact of a distressed family member on pediatric resuscitation teams.

October 7, 2020

Environmental Cleaning for the Prevention of Healthcare-Associated Infections (HAIs).

September 16, 2015

Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy.

December 2, 2015

ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical services and workforce-2021.

October 19, 2022

Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers.

September 23, 2020

2008 John M. Eisenberg Patient Safety and Quality Awards.

October 8, 2008

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene.

November 14, 2007

National drug shortages worsen during COVID-19 crisis: proposal for a comprehensive model to monitor and address critical drug shortages.

November 4, 2020

The impact of COVID-19 response on central line associated bloodstream infections and blood culture contamination rates at a tertiary care center in greater Detroit area.

December 16, 2020

Challenges with requiring five characters during ADC drug searches via override.

November 3, 2021

Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability.

August 16, 2006

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

July 11, 2023

Salzburg Global Seminar Session 565—Better Health Care: How Do We Learn About Improvement?

May 16, 2018

Improving medication reconciliation in hospitals.

August 31, 2022

Awareness of patient safety grows with increased outpatient surgeries.

October 8, 2014

Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior.

July 10, 2019

Knowledge-based information to improve the quality of patient care.

February 25, 2009

View More

Related Resources

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

August 23, 2023

Association of polypharmacy and potential drug-drug interactions with adverse treatment outcomes in older adults with advanced cancer.

July 19, 2023

WebM&M Cases

Misconnection Leading to Arterial Thrombosis

June 28, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

April 19, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

February 1, 2023

Prevent administration of ear drops into the eyes.

December 14, 2022

ISMP survey on tall man (mixed case) lettering to reduce drug name confusion.

November 16, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only.

February 3, 2021

WebM&M Cases

When the Indications for Drug Administration Blur

June 24, 2020

Perspective

Making Healthcare Safer III Report

March 30, 2020

Interview

In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD

March 30, 2020

Annual Perspective

Pharmacist Role in Patient Safety

February 21, 2020

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

A prescription for enhancing electronic prescribing safety.

December 12, 2018

Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention.

August 5, 2015

The contribution of labelling to safe medication administration in anaesthetic practice.

June 15, 2011

Pharmacy mixes up prescriptions.

February 16, 2011

Common cause analysis.

June 16, 2010

ISMP medication error report analysis.

June 9, 2010

ISMP medication error report analysis.

May 12, 2010

ISMP medication error report analysis.

April 21, 2010

Listen carefully: the risk of error in spoken medication orders.

April 14, 2010

ISMP medication error report analysis.

March 10, 2010

View More

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Indwelling Tubes and Catheters

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364