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Cases & Commentaries
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Journal Article > Study
Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.
Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.
This project studied the epidemiologic viability of using an injury surveillance system to track outpatient adverse drug events (ADEs) treated in hospital emergency departments. The authors found that the system could play a useful role in helping to understand outpatient ADEs, identifying areas for research, and monitoring ADE prevention.
Journal Article > Commentary
Cohen MC. Hosp Pharm. 2009;44:374-378.
This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, and reduce adverse events.
Journal Article > Study
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
In this study, investigators identified possible medication errors using trigger tools, and a multidisciplinary team conducted real-time analyses to identify underlying system flaws contributing to the errors.
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.
This article discusses incidents involving misadministration of IV insulin and makes recommendations to improve safety in delivering this high-alert medication.