Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 2
- Technologic Approaches
Search results for ""
- Computerized Adverse Event Detection
- Failure Mode Effects Analysis
- Health Care Executives and Administrators
Cases & Commentaries
- Web M&M
Hedy Cohen, RN, BSN, MS; February-March 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
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.