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Cases & Commentaries
- Web M&M
Tess Pape, PhD, RN, CNOR; February 2006
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
Journal Article > Study
Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.
Conducted by the American Society of Health-System Pharmacists (ASHP), this survey of more than 1300 pharmacy directors sought to evaluate the use of safety measures targeting medication dispensing and administration errors. Some positive signs were found in that use of proven technologies such as bar coding and smart infusion pumps has increased, but the overall proportion of hospitals using these technologies remains relatively low. Only a small proportion of hospitals had pharmacists attached to the emergency department (ED) or reviewed medication orders in the ED for errors. Prior surveys by the ASHP have examined the use of safety mechanisms for preventing prescribing and transcribing errors.