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- Communication Improvement(10)
- Computerized Decision Support(4)
- Computerized Provider Order Entry (CPOE)(2)
- Culture of Safety(2)
- Education and Training(9)
- Error Reporting and Analysis(4)
- Human Factors Engineering(3)
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ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4.
Pharmacy Practice News Special Edition. December 13, 2022: 43-54.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.
This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.
Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.
ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.
Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.