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- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Logistical Approaches 2
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- Identification Errors
- Medication Errors/Preventable Adverse Drug Events 6
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Perspectives on Safety > Interview
Bar Coding for Medication Safety, September 2008
Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women’s Hospital and Assistant Professor of Medicine at Harvard Medical School. Dr. Poon’s research has focused on using health information technology to improve patient safety. He oversees the development and implementation of clinical applications including computerized physician order entry (CPOE) and barcode-assisted electronic medication administration record, and was lead author on the first rigorous study demonstrating the impact of a bar coding system in a hospital pharmacy. We asked him to speak with us about how such technology can augment medication safety.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2005;40:844-847.
This monthly selection of medication error reports provides examples of drug misadministration, confusion with drug names, and administration of chemotherapy to the wrong patient, plus suggested United States adopted names for drugs.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Journal Article > Study
Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Am J Health Syst Pharm. 2007;64:90-96.
The authors implemented technologies supporting safe medication use and observed improved patient identification, decreased turnaround time for orders, and increased accuracy of medication administration.
ISMP Medication Safety Alert! Acute Care Edition. January 25, 2007;12:1.
This article discusses the weaknesses inherent in using the "five rights" for medication use as absolutes and suggests that they instead serve as broad goals to support safe medication practices.
Journal Article > Study
The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.
Franklin BD, O'Grady K, Donyai P, Jacklin A, Barber N. Qual Saf Health Care. 2007;16:279-284.
Measures that have been proposed to reduce the incidence of medication errors target prescribing safety (e.g., computerized provider order entry) or safety in administering medications (e.g., bar coding or automated dispensing). While each of these individual measures has been shown to decrease errors, as yet few systems "close the loop" by integrating safety measures for prescribing and administering medications. Utilizing an electronic system that incorporated CPOE, automated dispensing, bar coding, and an electronic medication record, this single-institution study demonstrated a significant reduction in both prescribing errors and administration errors. However, staff time spent on medication-related tasks increased. While the study results are promising, one caveat is that the system was not used for high-risk drugs such as anticoagulants or intravenous medications.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.