ISMP medication error report analysis.

Commentary

ISMP medication error report analysis.

July 5, 2006

Cohen MR.

View more articles from the same authors.

This monthly selection of medication error reports provides examples of nimodipine administration mishaps, a lithium overdose, and suggested adopted drug names for review.

Available at

Related Resources From the Same Author(s)

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.

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

ISMP medication error report analysis.

June 24, 2009

ISMP medication error report analysis.

December 9, 2009

ISMP medication error report analysis.

February 13, 2008

ISMP medication error report analysis.

December 3, 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.

August 26, 2009

ISMP medication error report analysis.

May 7, 2008

ISMP medication error report analysis.

December 5, 2007

Medication Errors. 2nd ed.

November 1, 2006

ISMP medication error report analysis.

January 20, 2010

ISMP medication error report analysis.

April 16, 2008

ISMP medication error report analysis.

June 4, 2008

ISMP medication error report analysis.

February 4, 2009

ISMP medication error report analysis.

October 28, 2009

ISMP medication error report analysis.

March 19, 2008

ISMP medication error report analysis.

October 29, 2008

ISMP medication error report analysis.

October 31, 2007

ISMP medication error report analysis.

June 9, 2010

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

March 6, 2005

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

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

March 24, 2010

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

Avoiding errors associated with insulin therapy.

May 27, 2009

ISMP medication error report analysis.

May 27, 2009

The Basics of FMEA. 2nd ed.

March 27, 2005

Pediatric safety incidents from an intensive care reporting system.

May 27, 2009

2008 John M. Eisenberg Patient Safety and Quality Awards.

October 8, 2008

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

May 16, 2018

ASPEN Parenteral Nutrition Safety Summit.

March 21, 2012

Errors and Malpractice in Radiology.

September 26, 2012

Drug shortages: a patient safety crisis.

September 7, 2011

Variation in medication information for elderly patients during initial interventions by emergency department physicians.

January 16, 2008

Pharmacy Education and Practice.

January 26, 2022

Crew resource management training--clinicians' reactions and attitudes.

September 28, 2005

Obstetric Quality and Safety.

October 28, 2009

Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention.

September 21, 2016

WebM&M Cases

Double Dosing, by the Rules

March 21, 2009

Medical errors: where are we now?

November 15, 2006

When machine learning goes off the rails. A guide to managing the risks.

March 3, 2021

The successful anesthesia patient safety officer.

September 15, 2021

WebM&M Cases

The 2-Week Itch

April 1, 2003

ACR guidance document on MR safe practices: updates and critical information 2019.

August 14, 2019

Diagnostic time-outs to improve diagnosis.

April 20, 2022

NQF Safe Practices: 2010 Updates.

March 17, 2010

Assessing patient safety culture in hospital settings.

June 2, 2021

A mixed methods evaluation of medication reconciliation in the primary care setting.

March 2, 2022

'More than words' - interpersonal communication, cognitive bias and diagnostic errors.

August 11, 2021

Frailty, gaps in care coordination, and preventable adverse events.

July 6, 2022

Mitigating racial bias in machine learning.

June 22, 2022

STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration.

October 14, 2016

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial.

August 18, 2021

Successful remediation of patient safety incidents: a tale of two medication errors.

March 2, 2011

Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning.

January 11, 2023

A pause in pediatrics: implementation of a pediatric diagnostic time-out.

September 14, 2022

Rates of serious surgical errors in California and plans to prevent recurrence.

May 19, 2021

Clinical reasoning in the wild: premature closure during the COVID-19 pandemic.

August 19, 2020

Reducing errors through discharge medication reconciliation by pharmacy services.

August 26, 2015

A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery.

September 22, 2021

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

December 7, 2022

Pediatric transport safety collaborative: adverse events with parental presence during pediatric critical care transport.

November 10, 2021

Medication safety in older adults: home-based practice patterns.

June 22, 2005

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

August 19, 2020

Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic.

February 10, 2021

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

January 18, 2023

WebM&M Cases

Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.

February 1, 2023

Long-term effects of teamwork training on communication and teamwork climate in ambulatory reproductive health care.

October 28, 2020

Differences in safety report event types submitted by graduate medical education trainees compared with other healthcare team members.

December 8, 2021

The threat within: mitigating the risk of medical error.

March 25, 2020

Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department.

September 30, 2020

Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop.

June 2, 2021

A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist.

February 2, 2022

Related Resources

Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the national reporting and learning system.

July 12, 2023

Anesthesia Patient Safety Podcast.

July 12, 2023

WebM&M Cases

Misconnection Leading to Arterial Thrombosis

June 28, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

National Patient Safety Goals.

December 20, 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

Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims.

November 4, 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

2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals.

May 11, 2017

Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.

November 2, 2016

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

August 5, 2015

Did hospital engagement networks actually improve care?

September 3, 2014

WebM&M Cases

The Forgotten Line

May 1, 2012

A multifaceted program for improving quality of care in intensive care units: IATROREF study.

April 18, 2012

Anticoagulation-associated adverse drug events.

December 14, 2011

Pharmacy mixes up prescriptions.

February 16, 2011

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

December 15, 2010

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

WebM&M Cases

Bad Writing, Wrong Medication

April 1, 2010

ISMP medication error report analysis.

March 10, 2010

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

February 17, 2010

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Indwelling Tubes and Catheters

Infusion Pumps

Discontinuities, Gaps, and Hand-Off Problems

ISMP medication error report analysis.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

ISMP medication error report analysis.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site