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- Error Reporting and Analysis
- Legal and Policy Approaches 1
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- Medication Safety 4
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Cases & Commentaries
- Spotlight Case
- Web M&M
Paul Barach, MD, MPH; February 2003
A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic.
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Journal Article > Study
Bates DW. Ann Intern Med. 2002;137:110-116.
This case study shares the experiences of a patient who suffered a medication error in receiving a dose of insulin inadvertently. The author reviews the epidemiology of medication errors and adverse drug events and shares a systems approach to medication errors, the role individuals and the system played in this particular case, and the potential prevention strategies to be considered. Finally, a comment about the institution's response to the event is presented to illustrate the importance of bridging what happens at the bedside with what needs to happen from the executive suite. This article is part of a collection entitled "Quality Grand Rounds," a series published in the Annals of Internal Medicine that explores quality issues and medical errors.
Journal Article > Study
Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS).
Varricchio F, Reed J, and the VAERS Working Group. South Med J. 2006;99:486-489.
The investigators analyzed medication errors submitted to a national database to assess whether they were true errors, the reasons for these errors, and responses to the errors.
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.