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Cases & Commentaries
- Web M&M
Donna L. Washington, MD, MPH; January 2004
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.
Journal Article > Study
Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out?
Suba EJ, Pfeifer JD, Raab SS. J Urol. 2007;178:1245-1248.
This study summarizes the findings from three root cause analyses to highlight the challenges in preventing patient identification errors in surgical pathology specimens. The authors suggest the use of a time-out strategy that would reduce the risk of the wrong patient receiving radiation or surgical therapy.
Journal Article > Commentary
Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.
ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
This article analyzes a fatal error involving parenteral nutrition and makes recommendations to prevent such incidents.