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- Communication Improvement 2
- Education and Training 2
- Error Reporting and Analysis 1
- Human Factors Engineering 3
- Quality Improvement Strategies 2
- Specialization of Care 2
- Technologic Approaches
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Errors/Preventable Adverse Drug Events 6
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
Tim Vanderveen, PharmD, MS; May 2009
Hospitalized for an elective procedure, a patient is given heparin in an incorrect concentration—off by a factor of 100.
Perspectives on Safety > Perspective
with commentary by Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN, Bar Coding for Medication Safety, September 2008
Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.
Journal Article > Study
Effectiveness of a computerized system for intravenous heparin administration: using information technology to improve patient care and patient safety.
Oyen LJ, Nishimura RA, Ou NN, Armon JJ, Zhou M. Am Heart Hosp J. 2005;3:75-81.
The investigators analyzed the efficacy of a computerized heparin nomogram system, which distributes interactive cues among the prescriber, nurse, pharmacist, and laboratory. They found significant improvements in the safety of this drug's administration.
Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.
This video story reviews a high-profile medication error and suggests actions to prevent similar incidents from occurring.
Journal Article > Commentary
Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.
This article summarizes results from a conference regarding heparin errors, their epidemiology, and error types along with ways to increase safety.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. September 24, 2008;(41):1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission.