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Dowdell EB. Pediatr Nurs. 2004;30:328-330.
Dowdell EB.Pediatric medical errors part 1: the case. A pediatric drug overdose case. Pediatr Nurs. 2004; 30: 328-330
The Forgotten Radiographic Read
Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD
Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.
Blandford A, Dykes PC, Franklin BD, et al. Drug Saf. 2019 Jun 13; [Epub ahead of print].
Independent double checks: worth the effort if used judiciously and properly.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study.
Seston EM, Ashcroft DM, Lamerton E, Harper L, Keers RN. BMC Health Serv Res. 2019;19:325.
Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia.
Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74:904-914.
When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer?
Gordon M. Health Shots. National Public Radio. April 10, 2019.
The effect of a residential care pharmacist on medication administration practices in aged care: a controlled trial.
McDerby N, Kosari S, Bail K, Shield A, Peterson G, Naunton M. J Clin Pharm Ther. 2019 Feb 21; [Epub ahead of print].
Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.
Leonard JB, Klein-Schwartz W. Am J Health Syst Pharm. 2019;76:264-265.
Use of a public health law framework to improve medication safety by anesthesia providers.
Litman RS. J Patient Saf Risk Manag. 2019 Feb 5; [Epub ahead of print].
Pro/con debate: color-coded medication labels.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
Increasing compliance of safe medication administration in pediatric anesthesia by use of a standardized checklist.
Kanjia MK, Adler AC, Buck D, Varughese AM. Paediatr Anaesth. 2019;29:258-264.
Evaluating a handheld decision support device in pediatric intensive care settings.
Reynolds TL, DeLucia PR, Esquibel KA, et al. JAMIA Open. 2019;2:49-61.
ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices.
Horsham, PA: Institute for Safe Medication Practices; 2018.
Blame: what does it look like?
Duthie EA. Nurs Manage. 2018;49:18-21.
IV push medications survey results—part 1 and part 2.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.
MacMaster HW, Gonzalez S, Maruoka A, et al. Jt Comm J Qual Patient Saf. 2019;45:380-386.
Validation of a mobile app for reducing errors of administration of medications in an emergency.
Baumann D, Dibbern N, Sehner S, Zöllner C, Reip W, Kubitz JC. J Clin Monit Comput. 2019;33:531-539.
Best Practices for Safe Medication Administration During Anesthesia Care.
APSF Committee on Technology. Anesthesia Patient Safety Foundation.
A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors.
Schnock KO, Dykes PC, Albert J, et al. Drug Saf. 2018;41:591-602.
Antidepressant and antipsychotic medication errors reported to United States poison control centers.
Kamboj A, Spiller HA, Casavant MJ, Chounthirath T, Hodges NL, Smith GA. Pharmacoepidemiol Drug Saf. 2018;27:902-911.
Making an infusion error: the second victims of infusion therapy-related medication errors.
Treiber LA, Jones JH. J Infus Nurs. 2018;41:156-163.
Visual acuity, literacy, and unintentional misuse of nonprescription medications.
Mullen RJ, Curtis LM, O'Conor R, et al. Am J Health Syst Pharm. 2018;75:e213-e220.
A quality initiative: a system-wide reduction in serious medication events through targeted simulation training.
Hebbar KB, Colman N, Williams L, et al. Simul Healthc. 2018;13:324-330.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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