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- Communication Improvement
- Education and Training
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- Quality Improvement Strategies 1
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- Identification Errors 1
- Medication Errors/Preventable Adverse Drug Events 2
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
Michael Cohen, RPh, MS, ScD (hon); April 2003
Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.
Journal Article > Study
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
This AHRQ-supported study analyzed information from nearly 3 million operations between 1985 and 2004, discovering a rate of 1 in 112,994 cases of wrong-site surgery. Investigators further evaluated cases with available medical records, all of which were among the malpractice claims. In doing so, they noted that the Joint Commission's Universal Protocol might have prevented only 62% of the cases reviewed. At the rates reported, the authors suggest that the average large hospital may be involved in such an event every 5 to 10 years, a rate 10 times less frequent than retained foreign bodies. They also point out that while wrong-site surgery is a devastating and unacceptable outcome, current efforts to implement protocols may not prevent every event and may, in turn, create inefficiency in related processes. The authors offer a series of recommendations for a model site-verification protocol. The American College of Surgeons offers a fact sheet on correct-site surgery geared toward patient education.
Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.