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Journal Article > Study
Kowiatek JG, Weber RJ, Skledar SJ, Frank S, DeVita M. Jt Comm J Qual Patient Saf. 2006;32:309-317.
This medication safety study describes a process to prevent unsafe medication dispensing from automated systems. Investigators evaluated the types and frequencies of medications administered by override, used an expert panel to revise the medication override list, developed a tool for override monitoring, and specifically measured the change in override use of opioids (a high-alert medication class). The authors discuss their multifaceted approach, present examples of the changes that resulted, and offer steps for other organizations interested in similar implementation strategies.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.