Narrow Results Clear All
- Communication Improvement 3
- Education and Training 2
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Quality Improvement Strategies 1
- Specialization of Care 2
- Clinical Information Systems 2
- Alert fatigue 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Errors/Preventable Adverse Drug Events 3
- 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.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
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.
Tools/Toolkit > Fact Sheet/FAQs
Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.
This briefing sheet reviews the opportunities, solutions, and drivers for medication safety improvements.