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- Medication Safety
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Journal Article > Commentary
Kovner C, Menezes J, Goldberg JD. Jt Comm J Qual Patient Saf. 2005;31:379-385.
In this AHRQ-funded study, the investigators reviewed the medication management process for home care and developed several recommendations to improve safety.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2006;55:1016-1017.
This article reports on an investigation into clusters of mistakes involving the misadministration of a vaccine.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Journal Article > Study
Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001–2011.
Guh AY, Thompson ND, Schaefer MK, Patel PR, Perz JF. Med Care. 2012;50:785-791.
This review documents 35 cases of unsafe injection practices in the United States over the past decade, leading to more than 100,000 patients being exposed to communicable diseases. In most cases, clinicians reused syringes or medication vials intended for single-dose usage. Although the authors ascribe these violations to failure to follow basic infection control practices, subsequent analysis of one widely publicized case also revealed that safety culture played a role, as nurses did not feel empowered to report improper injection practices due to fear of retaliation. The article also discusses the challenges of notifying patients about potential harm, and a recent Australian article describes the notification process used after a similar large-scale safety problem was identified.
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.
Tavernise S. New York Times. January 15, 2015.
This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.
Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.
Silver Spring, MD: US Food and Drug Administration; September 29, 2018.