Narrow Results Clear All
- Communication Improvement 2
- Education and Training
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Clinical Information Systems 2
- Device-related Complications 1
- Diagnostic Errors 2
- Medical Complications 3
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Transfusion Complications 1
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ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.
Anderson HJ. Health Data Manag. January 1, 2009;17:18.
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors, a mere 8% of hospitals use the system and fewer implement it effectively, according to the Leapfrog Group CPOE evaluation tool.
Journal Article > Commentary
Cohen MC. Hosp Pharm. 2009;44:374-378.
This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.
Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2009.
This public health notification raises awareness of the potential for falsely elevated blood glucose readings in patients using therapeutic products containing certain non-glucose sugars.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. January 26, 2010;(44):1-4.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will being distributed by a new initiative.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
This article discusses how several health care organizations used health information technology to improve organizational transparency.
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.