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- Communication Improvement
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Quality Improvement Strategies 1
- Clinical Information Systems 3
- Diagnostic Errors 1
- Identification Errors 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 2
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
Michael Cohen, RPh, MS, ScD (hon); April 2003
Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.
Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.
Gardner E. Mod Healthc. May 18, 2009;39:28-31.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
Landro L. Wall Street Journal. May 10, 2011:D3.
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving physician–nurse communication, adopting timeouts before discharge, and using trigger systems.