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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.
Crocker C. Nurs Times. 2009 Nov 24;105:12-15.
This article tracks the care of a United Kingdom National Health Service patient and identifies several areas for process improvement to ensure safe medication delivery.
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
Journal Article > Study
He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.
Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.
Although ensuring the correct patient receives the appropriate treatment may seem a straightforward task, patient misidentification has resulted in highly publicized errors. The Joint Commission has required standardized processes for avoiding patient misidentification as one of the National Patient Safety Goals. This qualitative study of nurses and residents identified barriers to following appropriate identification practices and characterizes workarounds that providers use to circumvent these perceived barriers. A near miss caused by a patient identification error is discussed in detail in this AHRQ WebM&M commentary.
Journal Article > Study
Catching and correcting near misses: the collective vigilance and individual accountability trade-off.
Jeffs LP, Lingard L, Berta W, Baker GR. J Interprof Care. 2012;26:121-126.
Detection and prevention of near misses depend on a balance between individual accountability and collective vigilance, according to interviews with clinicians of different disciplines at an academic medical center.