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Aboumatar HJ, Winner L, Davis R, et al. Jt Comm J Qual Patient Saf. 2010;36:79-86, AP1-AP4.
Aboumatar HJ ; Winner L ; Davis R; et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010; 36
This article describes how one hospital used failure mode and effect analysis to identify problems and design Six Sigma interventions to improve the reliability of chemotherapeutic agent preparation.
Don't underestimate the impact of change on risk potential.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
Fluorouracil error ends tragically, but application of lessons learned will save lives.
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2007;12:1-3.
Fluorouracil Incident Root Cause Analysis Report.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.
Robinson DL, Heigham M, Clark J. Jt Comm J Qual Patient Saf. 2006;32:161-166.
Patient involvement in evaluation of safety in oral antineoplastic treatment: a failure mode and effects analysis in patients and health care professionals.
Mattsson TO, Lipczak H, Pottegård A. Qual Manag Health Care. 2019;28:33-38.
Specifications of computerized provider order entry and clinical decision support systems for cancer patients undergoing chemotherapy: a systematic review.
Rahimi R, Kazemi A, Moghaddasi H, Arjmandi Rafsanjani K, Bahoush G. Chemotherapy. 2018;63:162-171.
Using failure mode and effects analysis to reduce patient safety risks related to the dispensing process in the community pharmacy setting.
Stojkovic T, Marinkovic V, Jaehde U, Manser T. Res Social Adm Pharm. 2017;13:1159-1166.
Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial.
Taylor-Phillips S, Wallis MG, Jenkinson D, et al. JAMA. 2016;315:1956-1965.
Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.
ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.
Safety strategies in an academic radiation oncology department and recommendations for action.
Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.
Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures.
Ashley L, Armitage G. J Patient Saf. 2010;6:210-215.
Improving insulin distribution and administration safety using Lean Six Sigma methodologies.
Yamamoto J, Abraham D, Malatestinic B. Hosp Pharm. 2010;45:212-224.
ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.
Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.
ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.
A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.
Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. Jt Comm J Qual Patient Saf. 2009;35:72-81.
Patient Safety Curriculum.
Ann Arbor, MI: National Center for Patient Safety.
Cohen MR. Hosp Pharm. 2008;43:696–698.
Cohen MR. Hosp Pharm. 2008;43:618-621.
Cohen MR. Hosp Pharm. 2008;43:445-448.
Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:884–888.
Potassium may no longer be stocked on patient care units, but serious threats still exist!
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2007;12:1-2.
Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:790-792.
Mistake-Proofing the Design of Health Care Processes.
Grout JR. Rockville, MD: Agency for Healthcare Research and Quality; May 2007. AHRQ Publication No. 07-P0020.
Establishing a culture for patient safety - the role of education.
Milligan FJ. Nurse Educ Today. 2007;27:95-102.
Patient Safety Certificate Program.
Armstrong Institute for Patient Safety and Quality. October 21-25, 2019; Armstrong Institute for Patient Safety and Quality, Baltimore, MD.
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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