Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 2
- Human Factors Engineering 6
- Legal and Policy Approaches 3
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 3
- Medication Safety 14
- Nonsurgical Procedural Complications 1
- Second victims 1
- Surgical Complications 2
- Transfusion Complications 1
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Cases & Commentaries
- Web M&M
Mark V. Williams, MD; July 2004
A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.
Special or Theme Issue
Hum Factors. Spring 2006;48:1-108.
This set of ten articles addresses the role that human factors plays in patient safety issues, including medication administration barcoding, virtual reality simulation, and decision support system acceptance.
Web Resource > Government Resource
National Blood Service Hospitals.
This Web site includes reports from audits on compliance with blood transfusion guidelines in the United Kingdom.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
Lin R-G II, Watanabe T. Los Angeles Times. November 22, 2007;A1.
This article reports on a non-fatal medication error that involved several neonates (including the newborn twins of actor Dennis Quaid) receiving a concentration of heparin 1000 times higher than intended. The discussion includes current hospital efforts to prevent medication errors and the growing interest in use of bar coding technology. A similar error captured headlines in 2006 when it caused the deaths of three infants.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
This article reports on an overdose caused by improper label placement on a patient controlled analgesia (PCA) pump and provides recommendations for preventing pump-related medication errors.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. September 24, 2008;(41):1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission.
Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.
This report summarizes findings from interviews with AHRQ-funded grantees who have implemented computerized provider order entry systems.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
Journal Article > Commentary
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.
Journal Article > Study
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.
Errors at the administration stage are common for intravenous medications. Programmable or smart infusion pumps are widely used as a means of preventing such errors. However, prior studies have found that smart pumps alone may not significantly reduce errors, as they do not eliminate wrong-patient errors and may be prone to workarounds. This study compared three types of pumps—traditional pumps, smart pumps, and smart pumps combined with bar-code technology—in a simulated inpatient unit. The results indicate that smart pumps may reduce administration errors when combined with bar-coding or when only "hard" (unchangeable) dosing limits are used. Ultimately, creation of a "closed-loop" system that integrates technological solutions to prescription and administration errors represents the optimal solution for eliminating medication errors.
Blum K. Pharmacy Practice News. November 16, 2011.
Exploring the impact of medication errors on clinicians, this article discusses efforts to support second victims affected by medical error.
Journal Article > Study
Henneman PL, Marquard JL, Fisher DL, et al. J Nurs Adm. 2012;42:562-566.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
Journal Article > Commentary
Development of a training program for bar-code–assisted medication administration in inpatient pharmacy.
Dartt LR, Schneider R. Am J Health Syst Pharm. 2010;67:1592-1594.
This commentary describes how a Veterans Affairs Medical Center implemented a multidisciplinary training effort to improve bar-code medication administration.
ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4.
Confusion due to look-alike and sound-alike medications are known to contribute to medication errors. Describing errors associated with a certain medication naming convention, this newsletter article offers recommendations to reduce risks related to these drugs, including labeling clarifications, storing medications separately, barcode scanning, and staff education.
Journal Article > Review
Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.
Strudwick G, Reisdorfer E, Warnock C, et al. J Nurs Care Qual. 2018;33:79-85.