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- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis 2
- Logistical Approaches 2
- Quality Improvement Strategies
- Specialization of Care 1
- Technologic Approaches 3
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 3
- Medication Safety 9
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for "Newspaper/Magazine Article"
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
This newsletter article reports results of a survey indicating when and why intravenous (IV) medications are unnecessarily diluted and makes recommendations to prevent this practice, such as including instructions in the medication administration record regarding dilution and educating nurses about risks. Medications were frequently diluted, which may lead to mislabeled syringes, IV medication contamination, and dosing errors.
Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0.
ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013;18:1-4.
This newsletter article discusses risks associated with vincristine administration, contributing factors, and strategies to prevent errors.
ISMP Medication Safety Alert! Acute Care Edition. June 13, 2013;18:1-4.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
CDC Vital Signs. March 2012:1-4.
This newsletter article and accompanying set of infographics describes strategies to help patients and health care providers prevent health care–associated infections.
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.
ISMP Medication Safety Alert! Acute Care Edition. April 9, 2009;14:1-3.
This article describes the risks of cross-contamination when using shared metered dose inhalers (MDIs) and discusses how standard protocol could help eliminate these problems.
ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.
This article describes instances of tissue injury as a result of the misadministration of Promethazine and provides recommendations to minimize the risk of this occurring.
PA-PSRS Patient Saf Advis. September 2006;3:1, 5-10.
This article discusses the Pennsylvania Patient Safety Reporting System (PA-PSRS) reports of skin tears and provides suggestions to help keep patients safe from this common injury.
Weiss GG. Med Econ. May 19, 2006; 83:47-49.
This article provides suggestions for physicians to ensure reliable follow-up on test results, including tracking forms, computerization, and staff compliance with processes.
Meisel Z. Slate. November 8, 2005.
In this article, an emergency medicine physician describes the work environment of emergency medical technicians and paramedics and why it is prone to error.
Bulletin of the American College of Surgeons; October 2005.
This statement briefly lists the American College of Surgeons' guidelines for preventing retention of sponges, sharps, instruments, and other items after surgery.
Joint Commission: The Source. September 2005;3:3-4,11.
This article provides tips for implementing a program to proactively assess risk in hospitals.