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1 - 19 of 19
Cohen MR.
This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.
Cohen MR.
This monthly selection of medication error reports describes mix-ups involving insulin being administered instead of heparin and discusses issues of software and staff unawareness leading to dosage mishaps.
Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.
In response to multiple incidents of registration-associated patient misidentification (eg, assigning a new patient an existing patient's medical record number), an interdisciplinary team used plan-do-study-act methodology to investigate the root cause of such errors and formulate solutions. Several system problems were identified, ranging from inadequate training of registrars to the lack of a true master list of patients' medical record numbers. The authors describe the iterative process used to identify and address sources of error at several points within the patient registration process.
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Cohen MR.
This monthly selection of medication error reports provides examples of drug misadministration, confusion with drug names, and administration of chemotherapy to the wrong patient, plus suggested United States adopted names for drugs.
Cohen MR.
This monthly selection of medication error reports discusses helpful tips for how to avoid similar mistakes. The primary focus of this segment is safety issues associated with the diabetic therapy Symlin.
National Health Service.
This Web site provide resources for improving patient safety in the National Health Service, including a place for practitioners to ask questions and share experiences with one another.