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- Communication Improvement 3
- Culture of Safety
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Technologic Approaches 3
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Errors/Preventable Adverse Drug Events 4
- Nonsurgical Procedural Complications 1
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Cases & Commentaries
- Web M&M
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.
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.