Narrow Results Clear All
- Communication Improvement 2
- Education and Training 1
- Error Reporting and Analysis 6
- Human Factors Engineering 5
- Quality Improvement Strategies 2
- Specialization of Care 1
- Clinical Information Systems 4
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Safety 8
Search results for "Newspaper/Magazine Article"
ISMP Medication Safety Alert! Acute Care Edition. June 30, 2011;16:1-2.
This article discusses problems associated with overreliance on barcode system audio confirmation and suggests strategies to improve the reliability of electronic medication administration systems.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
Gee T, Moorman BA. Patient Saf Qual Healthc. March/April 2011;8:14-17.
Highlighting dangers presented by alarm fatigue, modification, and miscommunication, this article discusses strategies to reduce such incidents.
Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.
This article discusses how several health care organizations used health information technology to improve organizational transparency.
ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.
This article discusses a case of data entry error in an electronic prescribing system, explains the contributing factors, and provides recommendations to prevent such errors.
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.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
ISMP Medication Safety Alert! Acute Care Edition. November 19, 2009;14:1-3.
This piece describes the dangers of "borrowing" dispensed medications as a workaround in the presence of pharmacy delays and shares strategies to eliminate the practice.
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
This article describes errors associated with bar coded medication administration and provides strategies to avoid mistakes that stem from workarounds and overrides, disruptions in the medication administration process, and pharmacy dispensing errors.
PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50.
This failure mode and effects analysis (FMEA) explores factors contributing to near miss and adverse events related to alarm response and provides strategies to prevent monitoring failures.
PA-PSRS Patient Saf Advis. May 2007;4(suppl 2):1-8.
This article shares findings from a workgroup that assessed the efficacy of pharmacy computer systems in detecting unsafe medication orders. The 30 Pennsylvania hospitals that participated in the workgroup found that their systems were not catching all unsafe orders.