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Journal Article > Commentary
Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.
Lum TE, Fairbanks RJ, Pennington EC, Zwemer FL. Acad Emerg Med. 2005;12:658-662.
Journal Article > Study
Siewert B, Sosna J, McNamara A, Raptopoulos V, Kruskal JB. Radiographics. 2008;28:623-638.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.