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- Medication Safety 2
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Cases & Commentaries
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Nils Kucher, MD; January 2006
Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.
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.