Narrow Results Clear All
- Communication Improvement 9
- Culture of Safety 3
- Education and Training 4
- Error Reporting and Analysis 5
- Human Factors Engineering 5
- Legal and Policy Approaches 7
- Policies and Operations 1
- Quality Improvement Strategies 14
- Specialization of Care 1
- Clinical Information Systems 3
- Device-related Complications 2
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Failure to rescue 1
- Interruptions and distractions 1
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 19
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 2
- Internal Medicine 15
- Surgery 1
- Nursing 3
- Pharmacy 9
- Family Members and Caregivers 2
- Health Care Executives and Administrators 17
Health Care Providers
- Nurses 6
Non-Health Care Professionals
- Media 1
- Patients 12
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Noncognitive Errors ("Slips & Lapses")
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
ISMP Medication Safety Alert! Acute Care Edition. November 6, 2014;19:1-4.
Despite the designation of proper labeling as a National Patient Safety Goal in 2006, the problem of unlabeled solutions and medications persists. This newsletter article outlines several incidents involving labeling issues that contributed to patient harm or death and provides strategies to reduce risks related to poor labeling practices, including ensuring labels are available in all settings that require them, using tall man lettering to differentiate look-alike drug names, and limiting access to solutions and medications.
Suares W. FOX 25 KOKH-TV. July 30, 2014.
This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.
ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.
To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.
Landro L. Wall Street Journal. June 9, 2014.
As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.
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.
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. 2014;19:1-3.
This newsletter article describes how changes in batch preparation processes can introduce opportunities for errors and suggests strategies to reduce such risks. Recommendations included providing visual alerts, limiting the amount of labels printed, and verifying labels before attaching them to the product.
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies problems related to the medication reconciliation process and includes methods to address them.
ISMP Medication Safety Alert! Acute Care Edition. November 14, 2013;18:1-4.
This newsletter article reports on concerns associated with chemotherapy preparations due to variations in concentration and recommends standardized preparation processes to address such risks.
Jaffe E. Fast Company. November 11, 2013.
This article reports on a British initiative that studied health care processes for the purpose of designing devices to prevent medical errors.
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.
Landro L. Wall Street Journal. September 30, 2013.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
ISMP Medication Safety Alert! Acute Care Edition. August 8, 2013;18:1-4.
Relating how an infant died after ingesting a medication patch, this newsletter article advocates for clinician and organizational engagement in educating consumers about risks.
Hartcollis A. New York Times. May 29, 2013:A18.
This newspaper article reports on efforts, such as remote video monitoring or distributing "red cards," to improve hand hygiene compliance in hospitals.
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.
Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.
This newsletter article describes the development of the Medications at Transitions and Clinical Handoffs (MATCH) toolkit and relates one hospital's experience implementing it.
Kenler AS. Patient Saf Qual Healthc. July/August 2012;9:40-42.
This article discusses concerns with the diagnostic testing process and recommends that time outs can reduce risks.
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.
ISMP Medication Safety Alert! Acute Care Edition. June 28, 2012;17:1-3.
This newsletter article discusses an error involving a parenteral nutrition order and recommends strategies to prevent errors associated with automated compounding devices and order entry software.