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- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Technologic Approaches 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events
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Cases & Commentaries
- Web M&M
Michael Cohen, RPh, MS, ScD (hon); April 2003
Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2007;42:181–182.
This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values.