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This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.
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Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.
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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.
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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.
This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.
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Cohen MR; Smetzer JL.
This monthly selection of error reports discusses incidents involving incomplete administration of a two-part pediatric vaccine and drug name confusion.
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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.
This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.
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Cohen MR.
This monthly selection of error reports discusses incidents involving insulin preparation, automated medication cabinet stocking, and medication list filing.
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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.
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Cohen MR.
This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers.
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Cohen MC.
This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.
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Cohen MR.
This monthly selection of reports discusses an error involving the routing of a printed label in the pharmacy, describes examples of drug name confusion, and highlights an obscure drug concentration change.
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Cohen MR; Smetzer JL.
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.
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Cohen MR.
This monthly selection reports on pump programming errors that led to overdoses of patient-controlled analgesia (PCA), miscommunication regarding dose and indication for alteplase, and a warning to not use empty prelabeled syringes.
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Smetzer JL; Cohen MR.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.
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Smetzer JL; Cohen MR.
This monthly selection of reports includes errors involving epidural medication administered intravenously and mistaken reuse of discontinued drugs.
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Cohen MR.
This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child.
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Cohen MR.
This monthly selection of medication error reports addresses examples of unclear dose preparation instructions, potential insulin storage mix ups, and drug name confusion.
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Cohen MR.
This monthly selection of medication error reports includes examples of errors due to drug labels and dosage as well as danger with look-alike, color-coded eye medications.
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Cohen MR.
This monthly selection of medication error reports includes examples of look-alike/sound-alike medications and a discussion of immunosuppressant dosing errors.
