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Kimchi-Woods J, Shultz JP. Jt Comm J Qual Patient Saf. 2006;32:373-381.
Kimchi-Woods J ; Shultz JP.Using HFMEA to assess potential for patient harm from tubing misconnections. Jt Comm J Qual Patient Saf. 2006; 32: 373-381
The authors describe a health failure mode and effects analysis to explore system and behavioral factors that contribute to tubing misconnections.
Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections.
Chandonnet CJ, Kahlon PS, Rachh P, et al. Pediatrics. 2013;131:e1961-e1969.
Luer Connector Misconnections: Under-Recognized but Potentially Dangerous Events.
Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration.
Tubing misconnections: normalization of deviance.
Simmons D, Symes L, Guenter P, Graves K. Nutr Clin Pract. 2011;26:286-293.
Considering insulin pens for routine hospital use? Consider this...
ISMP Medication Safety Alert! Acute Care Edition. May 8, 2008;13:1-3.
Enteral feeding misconnections: a consortium position statement.
Guenter P, Hicks RW, Simmons D, et al. Jt Comm J Qual Patient Saf. 2008;34:285-292.
Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.
Simmons D, Phillips MS, Grissinger M, Becker SC. Jt Comm J Qual Patient Saf. 2008;34:293-296.
Tubing misconnections—a persistent and potentially deadly occurrence.
Sentinel Event Alert. April 3, 2006;(36):1-3.
FDA to end program that hid millions of reports on faulty medical devices.
Jewett C. Kaiser Health News. May 3, 2019.
Transcription errors of blood glucose values and insulin errors in an intensive care unit: secondary data analysis toward electronic medical record–glucometer interoperability.
Sowan AK, Vera A, Malshe A, Reed C. JMIR Med Inform. 2019;7:e11873.
Unintended patient safety risks due to wireless smart infusion pump library update delays.
Hsu KY, DeLaurentis P, Bitan Y, Degnan DD, Yih Y. J Patient Saf. 2019;15:e8-e14.
High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice.
Marwitz KK, Giuliano KK, Su WT, Degnan D, Zink RJ, DeLaurentis P. Res Social Adm Pharm. 2019;15:889-894.
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.
Simulation safety first: an imperative.
Raemer D, Hannenberg A, Mullen A. Simul Healthc. 2018;13:373-375.
Insulin pumps have most reported problems in FDA database.
Mohr H, Weiss M. Associated Press. November 27, 2018.
Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review.
Papadopoulos I, Koulouglioti C, Ali S. Contemp Nurse. 2018;54:425-442.
Reducing treatment errors through point-of-care glucometer configuration.
Estock JL, Pham IT, Curinga HK, et al. Jt Comm J Qual Patient Saf. 2018;44:683-694.
Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
Principles of automation for patient safety in intensive care: learning from aviation.
Dominiczak J, Khansa L. Jt Comm J Qual Patient Saf. 2018;44:366-371.
Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety.
Giuliano KK. Crit Care Nurs Clin North Am. 2018;30:215-224.
Patient safety in complementary medicine through the application of clinical risk management in the public health system.
Rossi EG, Bellandi T, Picchi M, et al. Medicines (Basel). 2017;4:E93.
Preventing blood transfusion failures: FMEA, an effective assessment method.
Najafpour Z, Hasoumi M, Behzadi F, Mohamadi E, Jafary M, Saeedi M. BMC Health Serv Res. 2017;17:453.
Using prospective risk analysis tools to improve safety in pharmacy settings: a systematic review and critical appraisal.
Stojkovic T, Marinkovic V, Manser T. J Patient Saf. 2017 Jun 29; [Epub ahead of print].
Intravenous smart pump drug library compliance: a descriptive study of 44 hospitals.
Giuliano KK, Su WT, Degnan DD, Fitzgerald K, Zink RJ, DeLaurentis P. J Patient Saf. 2018;14:e76-e82.
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.
More than half a million heart surgery patients at risk of a dangerous infection.
Sun LH. The Washington Post. October 13, 2016.
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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