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- Communication Improvement 1
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems
- Alert fatigue 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 1
- Medication Safety 5
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.
OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.
This report shares successful patient safety strategies employed in Ontario hospitals to address medication safety, patient incident management, infection issues, and administrative process improvements.
Journal Article > Study
Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department.
Sard BE, Walsh KE, Doros G, et al. Pediatrics. 2008;122:782-787.
Standardizing care processes, through the use of checklists and other approaches, has been demonstrated to improve patient safety by reducing health care–associated infections and handoff errors. This study implemented a standardized "quicklist" of commonly used pediatric medications within an existing computerized provider order entry system. Although use of the quicklist was not mandatory, prescribing errors were significantly reduced, especially among those providers who used the quicklist regularly. The study provides an example of how standardization combined with decision support can improve medication safety.
Journal Article > Review
'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care—a review of the literature.
Kullberg A, Larsen J, Sharp L. Eur J Oncol Nurs. 2013;17:228-235.
Cancer patients undergoing chemotherapy may be particularly vulnerable to medical errors, as their care often requires use of high-risk medications and must be closely coordinated between multiple physicians. This thematic review focused on methods to improve safety for chemotherapy patients and found evidence that computerized provider order entry could reduce medication errors. However, the authors did not find enough evidence to recommend other interventions that have been proposed, such as patient engagement or teamwork training for patients and families. An AHRQ WebM&M commentary discusses how one institution responded to a serious chemotherapy error.
Journal Article > Study
Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy.
Suzuki S, Chan A, Nomura H, Johnson PE, Endo K, Saito S. J Oncol Pharm Pract. 2017;23:18-25.
Chemotherapy is known to be a high-risk treatment that requires specific safety protocols. This study found that pharmacy checks of physician chemotherapy orders entered via computer order entry do uncover errors. The authors conclude that electronic prescribing is not sufficient to ensure safe chemotherapy prescription and recommend maintaining the role of oncology pharmacists.