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- Communication Improvement 2
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Specialization of Care 2
- Technologic Approaches 2
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 1
- Medication Safety 4
- Surgical Complications 2
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Journal Article > Commentary
Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.
Graudins LV, Downey G, Bui T, Dooley MJ. Jt Comm J Qual Patient Saf. 2016;42:86-95.
Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.
Journal Article > Government Resource
de Boer M, Boeker EB, Ramrattan MA, et al. Int J Clin Pharm. 2013;35:744-752.
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.
Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.
Rockville, MD: United States Pharmacopeia; 2007.
This report shares findings from analysis of more than 11,000 perioperative medication errors reported through Medmarx and includes recommendations to avoid these types of errors.
Vecchione A. Drug Topics. July 11, 2005;149:24.
This article summarizes the 2006 Joint Commission on Accreditation of Healthcare Organizations patient safety goals and how hospital pharmacists can contribute to their successful implementation.