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- Communication Improvement 2
- Culture of Safety 2
- Error Reporting and Analysis
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Interruptions and distractions 1
- Medication Safety 5
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Cases & Commentaries
- Web M&M
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.
Journal Article > Commentary
Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.
The authors outline the practical considerations in developing a medication patient safety program, including establishing a blame-free environment and collecting and analyzing error data.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2007;12:1-3.
This article summarizes an incident involving chemotherapeutic agent overdose, describes factors contributing to the error, and provides recommendations for safer chemotherapy administration.
Journal Article > Study
Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.
This case study examines an organizational response to a serious adverse event—a medication error in the intensive care unit that caused serious patient harm. Although a root cause analysis (RCA) was eventually convened, resulting in implementation of a systematic solution, prior to the RCA each professional group involved (nurses, pharmacists, and physicians) had already decided on individual approaches and solutions to the error. This resulted in unnecessary conflict and delays in reaching a workable solution to the problem.