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- Communication Improvement 2
- Human Factors Engineering 2
- Policies and Operations 1
- Quality Improvement Strategies 2
- Technologic Approaches 3
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medication Errors/Preventable Adverse Drug Events 3
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Journal Article > Study
Raebel MA, Carroll NM, Kelleher JA, Chester EA, Berga S, Magid DJ. J Am Med Inform Assoc. 2007;14:440-450.
The researchers tested the effectiveness of computerized decision support to minimize the use of contraindicated medicines in pregnant patients and found that it improved prescribing safety.
Barbella M. Drug Topics. October 8, 2007;151:18.
This article reports how a failure to perform medication reconciliation during patient transfer led to a mother being separated from her newborn daughter for several months.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2009;44:654-657.
This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.