Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Quality Improvement Strategies 3
- Specialization of Care 1
- Technologic Approaches
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 1
- Medication Errors/Preventable Adverse Drug Events
- Nonsurgical Procedural Complications 1
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Cases & Commentaries
- Web M&M
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.
Chun D. Gainsville Sun. August 21, 2006.
This article describes a computerized drug ordering and dispensing system at a Florida hospital.
Journal Article > Study
The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.
Franklin BD, O'Grady K, Donyai P, Jacklin A, Barber N. Qual Saf Health Care. 2007;16:279-284.
Measures that have been proposed to reduce the incidence of medication errors target prescribing safety (e.g., computerized provider order entry) or safety in administering medications (e.g., bar coding or automated dispensing). While each of these individual measures has been shown to decrease errors, as yet few systems "close the loop" by integrating safety measures for prescribing and administering medications. Utilizing an electronic system that incorporated CPOE, automated dispensing, bar coding, and an electronic medication record, this single-institution study demonstrated a significant reduction in both prescribing errors and administration errors. However, staff time spent on medication-related tasks increased. While the study results are promising, one caveat is that the system was not used for high-risk drugs such as anticoagulants or intravenous medications.
ISMP Medication Safety Alert! Acute Care Edition. August 23, 2007;12:1-3.
This article discusses the myriad dosing methods that can lead to errors in administering intravenous medications and programming infusion pumps.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2009;44:730-733.
This monthly selection of error reports discusses incidents involving insulin preparation, automated medication cabinet stocking, and medication list filing.
Journal Article > Study
Deng Y, Lin AC, Hingl J, et al. Am J Health Syst Pharm. 2016;73:887-893.
Mistakes during preparation of intravenous (IV) medications can lead to dosing errors and adverse drug events. Analyzing data collected over 12 months in a hospital's automated IV compounding workflow management system, this study found that IV compounding errors occurred in less than 1% of cases and were usually intercepted through the automated system. These results suggest that existing processes do support safe medication use.