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Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Norman DA. New York, NY: Basic Books; 2002.
Norman, a cognitive psychologist, outlines the elements of effective user-centered design, which include making the inner workings of devices visible, exploiting natural function, controlling relationships, and using constraints successfully. Through both fable and anecdote, Norman illustrates forcing functions and how bad design can exacerbate the consequences of human error. This classic text is a valuable introduction to the role of design in patient safety. [Note: Originally published in 1988 as The Psychology of Everyday Things.]
Journal Article > Commentary
Pearlman MD. Obstet Gynecol. 2006;108:1266-1271.
The author proposes changes in four areas of obstetrics and gynecology to facilitate changes for patient safety: improvement measurement, closed claim review, safe-design product development, and integrated safety education.
Web Resource > Multi-use Website
World Health Organization.
Journal Article > Study
High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice.
Marwitz KK, Giuliano KK, Su WT, Degnan D, Zink RJ, DeLaurentis P. Res Social Adm Pharm. 2019;15:889-894.
This retrospective study of smart infusion pump use across multiple hospitals found that the majority of pump alerts are overridden by clinicians, regardless of the type of pump or whether the medication is a high-alert medication. These results suggest a need to augment alerting algorithms to prevent alert fatigue and improve safety.