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- Communication Improvement 1
- Error Reporting and Analysis 1
- Human Factors Engineering
- Policies and Operations 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 1
- Alert fatigue 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medication Errors/Preventable Adverse Drug Events 2
- Transfusion Complications 1
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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 > Study
Quillen K, Murphy K. Arch Pathol Lab Med. 2006;130:1196-1198.
The authors collected data on specimen mislabeling and implemented an intervention to provide timely feedback to emergency department staff, after which major mislabeling decreased from 47% to 14%.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.