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Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
This report shares findings from a root cause analysis of a medication error incident that led to a patient's death. The report discusses systems failures that contributed to the event, as well as recommendations to improve safety.
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.
The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference.
Sanborn M, Gabay M, Moody ML. Hosp Pharm. 2009;44:159-164.
ISMP medication error report analysis.
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.
Smart pump custom concentrations without hard "low concentration" alerts.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.
The impact of type of manual medication cart filling method on the frequency of medication administration errors: a prospective before and after study.
Schimmel AM, Becker ML, van den Bout T, Taxis K, van den Bemt PM. Int J Nurs Stud. 2011;48:791-797.
Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process.
Aboumatar HJ, Winner L, Davis R, et al. Jt Comm J Qual Patient Saf. 2010;36:79-86, AP1-AP4.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.
Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.
ISMP Medication Safety Alert! Acute Care Edition. October 22, 2009;14:1-3.
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.
Cohen MR. Hosp Pharm. 2008;43:960-964.
Don't underestimate the impact of change on risk potential.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
Misprogramming PCA concentration leads to dosing errors.
ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.
Cohen MR. Hosp Pharm. 2008;43:547-550, 554.
Cohen MR. Hosp Pharm. 2008;43:445-448.
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.
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.
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.
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.
Strategies for optimizing OR drug safety.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Administering and monitoring high-alert medications in acute care.
Cajanding JMR. Nurs Stand. 2017;31:42-52.
An acetaminophen icon helps reduce medication decision errors in an experimental setting.
Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.
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.
Nursing strategies to increase medication safety in inpatient settings.
Bravo K, Cochran G, Barrett R. J Nurs Care Qual. 2016;31:335-341.
Metric units and the preferred dosing of orally administered liquid medications.
Neville K, Galinkin JL, Green TP, et al; Committee on Drugs of the American Academy of Pediatrics. Pediatrics. 2015;135:784-787.
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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