Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

Eric Ford; Koren Smith; Kendra Harris; Stephanie Terezakis

Study

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

January 16, 2013

Ford E, Smith K, Harris K, et al. Med Phys. 2012;39(11):6968-71.

View more articles from the same authors.

Analysis of voluntarily reported errors in radiation therapy treatments resulted in systematic changes to treatment planning and delivery. After the system improvements were implemented, no similar errors occurred and multiple near misses were detected before patients were affected.

PubMed citation

Available at

Related Resources From the Same Author(s)

Safety strategies in an academic radiation oncology department and recommendations for action.

January 30, 2005

The impact of health system membership on patient safety initiatives.

January 9, 2008

Incident learning in radiation oncology: a review.

August 15, 2018

Hospital responses to the Leapfrog Group in local markets.

February 20, 2008

Managed care penetration and other factors affecting computerized physician order entry in the ambulatory setting.

March 7, 2007

Appropriate use of medical interpreters.

November 19, 2014

Examining medical office owners and clinicians perceptions on patient safety climate.

November 7, 2018

How differences between manager and clinician perceptions of safety culture impact hospital processes of care.

February 14, 2018

Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

June 7, 2017

Incomplete EHR adoption: late uptake of patient safety and cost control functions.

September 19, 2007

A radiation oncology-specific automated trigger indicator tool for high-risk near-miss safety events.

March 4, 2020

Ethical issues in patient safety research: a systematic review of the literature.

September 9, 2015

Predicting computerized physician order entry system adoption in US hospitals: can the federal mandate be met?

January 23, 2008

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.

April 12, 2023

Assessing the relationship between patient safety culture and EHR strategy.

July 20, 2016

Disruptive behaviour in the perioperative setting: a contemporary review.

February 1, 2017

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

New graduate registered nurses: Risk mitigation strategies to ensure safety and successful transition to practice.

August 3, 2022

How residents think and make medical decisions: implications for education and patient safety.

August 15, 2007

Patient safety: the patient's role.

February 14, 2007

Using the patient safety indicators to detect potential safety events among US veterans with psychotic disorders: clinical and research implications.

August 1, 2012

What happens to the medication regimens of older adults during and after an acute hospitalization?

September 11, 2013

Clinical triggers: an alternative to a rapid response team.

March 4, 2009

Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.

July 19, 2006

Speaking up to reduce noise in the OR.

July 22, 2015

Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized, controlled trial.

December 21, 2005

Surgical safety checklist compliance: a job done poorly!

September 11, 2013

Family alert: implementing direct family activation of a pediatric rapid response team.

October 28, 2009

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

May 24, 2023

Posthospital medication discrepancies: prevalence and contributing factors.

September 21, 2005

Patient safety education 20 years after the Institute of Medicine report: results from a cross-sectional national survey.

May 20, 2020

Impact of feeling responsible for adverse events on doctors' personal and professional lives: the importance of being open to criticism from colleagues.

July 25, 2007

The courage to speak out: a study describing nurses' attitudes to report unsafe practices in patient care.

August 14, 2019

Systematic evaluation of errors occurring during the preparation of intravenous medication.

February 13, 2008

Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.

July 1, 2009

A blinded, prospective study of error detection during physician chart rounds in radiation oncology.

October 14, 2020

Inappropriate prescribing of opioids for patients undergoing surgery.

December 21, 2022

Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department.

March 6, 2005

Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit.

October 26, 2005

Chemotherapy error: practical approaches to increasing patient safety.

May 31, 2006

Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.

September 1, 2021

When the misdiagnosis is child abuse.

September 2, 2020

Beam me up Scotty! Impact of personal wireless communication devices in the emergency department.

November 24, 2010

Variations by state in physician disciplinary actions by US medical licensure boards.

April 13, 2016

Sir Karl Popper, swans, and the general practitioner.

November 16, 2011

Responses of physicians to an objective safety and quality knowledge test: a cross-sectional study.

October 6, 2021

Errors and omissions in anesthesia: a pilot study using a pilot's checklist.

July 13, 2005

Racial bias in cesarean decision-making.

May 10, 2023

Hospital readmission and parent perceptions of their child's hospital discharge.

September 4, 2013

Building nursing intellectual capital for safe use of information technology: a systematic review.

February 9, 2011

Bedside shift report improves patient safety and nurse accountability.

July 28, 2010

Patient safety: planting the seed.

July 20, 2005

Caution: coloured medication and the colour blind.

September 30, 2009

Medical malpractice in the People's Republic of China: the 2002 regulation on the handling of medical accidents.

October 26, 2005

We may remember but what did we learn? Dealing with errors, crimes and misdemeanours around adverse events in healthcare.

November 25, 2009

Rolling out the rapid response team.

June 1, 2011

Exploring situational awareness in diagnostic errors in primary care.

September 21, 2011

The problem with checklists.

July 15, 2015

Management of the deteriorating adult patient: does simulation-based education improve patient safety?

November 24, 2021

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

March 13, 2013

Sociotechnical work system approach to occupational fatigue.

July 26, 2023

Effective communication with primary care providers.

October 1, 2014

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

August 25, 2010

Perspective: a business school view of medical interprofessional rounds: transforming rounding groups into rounding teams.

November 14, 2012

What causes delays in diagnosing blood cancers? A rapid review of the evidence.

July 5, 2023

Student perceptions of medical errors: incorporating an explicit professionalism curriculum in the third-year surgery clerkship.

May 14, 2008

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

August 31, 2011

Wristbands as aids to reduce misidentification: an ethnographically guided task analysis.

September 28, 2011

Improving the usability of intravenous medication labels to support safe medication delivery.

September 7, 2011

Falls prevention at Mayo Clinic Rochester: a path to quality care.

May 9, 2007

Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight?

March 1, 2006

Problems with medical devices may be severely under-reported.

June 8, 2005

Medication errors in critical care: risk factors, prevention and disclosure.

May 13, 2009

Lessons learned from implementing a principled approach to resolution following patient harm.

January 9, 2019

"Managing up" can improve teamwork in the OR.

May 26, 2010

Thinking ethically about medical mistakes.

March 13, 2013

Reducing near miss medication events using an evidence-based approach.

July 27, 2022

The COVID-19 pandemic: resilient organisational response to a low-chance, high-impact event.

July 15, 2020

I'm sorry: laws that support apologies in health care.

February 5, 2020

Sidelining safety — the FDA's inadequate response to the IOM.

September 12, 2007

Origin and uses of primum non nocere—above all, do no harm!

May 4, 2005

Effect of a weight-based prescribing method within an electronic health record on prescribing errors.

November 25, 2009

Shifting indirect patient care duties to after hours in the era of work hours restrictions.

May 11, 2011

Content analysis of team communication in an obstetric emergency scenario.

September 16, 2009

Competencies for patient safety and quality improvement: a synthesis of recommendations in influential position papers.

April 6, 2016

Caregivers' perception of drug administration safety for pediatric oncology patients.

April 16, 2014

Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods.

January 21, 2015

Implementation science: a neglected opportunity to accelerate improvements in the safety and quality of surgical care.

December 21, 2016

Tackling communication barriers between long-term care facility and emergency department transfers to improve medication safety in older adults.

September 2, 2015

Residents, responsibility, and error: how residents learn to navigate the intersection.

August 16, 2023

The prosecution of RaDonda Vaught: an ethical and legal mistake.

December 21, 2022

Toward the eradication of medical diagnostic errors.

February 14, 2024

Reporting of unsafe conditions at an academic women and children's hospital.

September 29, 2021

Impact of resident workload and handoff training on patient outcomes.

April 4, 2012

Distractions and the anaesthetist: a qualitative study of context and direction of distraction.

May 22, 2013

Standardization and visualization of the surgical time-out.

October 4, 2023

Enhancing the quality and safety of the perioperative patient.

February 7, 2018

Integrating quality and safety content into clinical teaching in the acute care setting.

June 13, 2007

Exploring the barriers to learning from crisis: organizational learning and crisis.

November 14, 2007

Towards an organization with a memory: exploring the organizational generation of adverse events in health care.

June 8, 2005

Related Resources

Radiologist age and diagnostic errors.

October 18, 2023

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.

September 13, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

WebM&M Cases

Ventricular Wall Injury during a Diagnostic Cardiac Catheterization

June 28, 2023

Reducing errors resulting from commonly missed chest radiography findings.

May 31, 2023

Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update.

May 17, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspective

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Interview

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

Factors impacting on patient setup analysis and error management during breast cancer radiotherapy.

November 9, 2022

Rethinking use of air-safety principles to reduce fatal hospital errors.

September 7, 2022

Identifying patients whose symptoms are underrecognized during treatment with breast radiotherapy.

May 4, 2022

Error and cognitive bias in diagnostic radiology.

April 13, 2022

Quality Special Issue.

April 13, 2022

Preventing and mitigating radiology system failures: a guide to disaster planning.

February 2, 2022

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

June 30, 2021

A qualitative study of what care workers do to provide patient safety at home through telecare.

June 23, 2021

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

September 2, 2020

Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology.

February 12, 2020

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

September 11, 2019

Advances in Human Factors and Ergonomics in Healthcare and Medical Devices.

September 11, 2019

Patient Safety Primers

Patient Safety 101

September 7, 2019

Perceptual and interpretive error in diagnostic radiology—causes and potential solutions.

September 4, 2019

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

End-to-end lung cancer screening with three-dimensional deep learning on low-dose chest computed tomography.

June 5, 2019

Using near-miss events to improve MRI safety in a large academic centre.

May 15, 2019

Patient safety in medical imaging: a joint paper of the European Society of Radiology (ESR) and the European Federation of Radiographer Societies (EFRS).

May 8, 2019

Governing the safety of artificial intelligence in healthcare.

May 8, 2019

See More About The Topic

Hospitals

Health Care Providers

Risk Managers

Engineers

Radiology

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Patient Safety 101

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site