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- Communication Improvement 3
- Education and Training 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 2
- Alert fatigue 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Safety 3
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Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Journal Article > Commentary
Cohen MC. Hosp Pharm. 2009;44:374-378.
This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.