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- Communication Improvement 1
- Education and Training 4
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events
- Nonsurgical Procedural Complications 1
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Cases & Commentaries
- Web M&M
Michael Astion, MD, PhD; June 2004
Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.
This alert notifies health care providers of the potential for patient harm if a particular inhalation powder is reconstituted and incorrectly administered.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
Journal Article > Study
Pugliese G, Gosnell C, Bartley JM, Robinson S. Am J Infect Control. 2010;38:789-798.
This study surveyed more than 5000 providers who reported elements of unsafe injection practices, including use of single-dose/use vials for more than one patient, and reuse of syringes.
Wright J. Nursing Times. 2013;109:11-14.
This record review study found that omitted doses of antimicrobial medications occur frequently in hospital settings in the United Kingdom.
Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors.
ISMP Medication Safety Alert! Acute Care Edition. March 13, 2014;19:1-2,4-5.
Summarizing results from a national survey investigating vaccine administration errors, this article outlines recommendations to reduce risks associated with the use and packaging of vaccines. Tips include establishing protocols for commonly used vaccines, requiring periodic training for staff, and labeling prepared syringes.
ISMP Medication Safety Alert! Acute Care Edition. May 22, 2014;19:1-2.
Errors occur frequently in vaccine administration when packaging instructions for diluents are unclear. This newsletter article offers recommendations for manufacturers and practitioners to reduce risks related to vaccines.