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- WebM&M Cases 3
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- Medication Errors/Preventable Adverse Drug Events
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Search results for ""
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.
Cases & Commentaries
- Web M&M
James E. Heubi, MD ; January 2006
Parents of a 5-year-old, told to give their son acetaminophen for his fever, return 2 days later because he is acutely ill. Tests reveal dangerously high acetaminophen levels. It turns out the parents had miscalculated the dosage.
Cases & Commentaries
- Web M&M
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.
Journal Article > Commentary
Medication errors in family practice, in hospitals and after discharge from the hospital: an ethical analysis.
Clark PA. J Law Med Ethics. 2004;32:349-357.
In this article, the author urges the medical community to universally apply the systems approach to safety toward the reduction of medical errors. The author calls for health care to take medication errors more seriously and for patients to help drive improvement.
Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.
Carbasho T. Pittsburgh Business Times. April 25, 2005.
This article reports on Ohio Valley General Hospital's intravenous safety system. Using bar code scanning to provide important patient information, the system automates checks for intravenous medication administration.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
Meisel Z. Slate. November 8, 2005.
In this article, an emergency medicine physician describes the work environment of emergency medical technicians and paramedics and why it is prone to error.
Berwick DM. Newsweek. December 12, 2005;46:75-78.
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K Lives Campaign.
Greene L. St. Petersburg Times. June 15, 2006:A1.
This article reports on the death of a pregnant 18-year-old after an overdose of magnesium sulfate.
Oakeshott I. The Sunday Times. June 18, 2006.
This article reports on incidents of wrong drug and wrong route administration of epidurals in the United Kingdom's National Health Service.
Bruce D. Erie Times-News. July 2, 2006:1.
This article shares the story of a patient who suffered serious damage after being prescribed the wrong medication during a hospital stay. It is accompanied by a second article that follows a patient through her care to illustrate the precautions hospitals are taking to prevent medical error.
Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].
This article reports on efforts to reduce use of certain medications and instruments that can cause harm during labor and delivery.
BBC News. August 11, 2006.
This story reports findings from the UK Healthcare Commission's assessment of medication error in the National Health Service. The story is accompanied by an audiovisual news report.
Chun D. Gainsville Sun. August 21, 2006.
This article describes a computerized drug ordering and dispensing system at a Florida hospital.
Davies T. Washington Post. September 22, 2006.
This article reports on the deaths of three infants from heparin overdoses and describes how the hospital community has responded to the errors.
Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.
This article reports on criminal charges brought against a nurse after she committed a medication error.
News 3 Las Vegas (KVBC/DT). December 7, 2006.
This news story describes an incident involving the death of a premature infant due to a zinc overdose administered through nutritional fluid.
Colvin G. "The Colvin Interview." CNN. February 5, 2007.
This video segment features an interview with two McKesson executives about how health information technology can help prevent medication errors.