Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 2
- Education and Training 4
- Error Reporting and Analysis 3
- Human Factors Engineering 4
- Legal and Policy Approaches 1
- Quality Improvement Strategies 5
- Technologic Approaches 1
- Device-related Complications 1
- Identification Errors 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events
- Psychological and Social Complications 1
- Surgical Complications 1
Search results for "Book/Report"
- Administration Errors
Horsham, PA: Institute for Safe Medication Practices; 2017.
This updated report outlines 14 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has expanded since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts.
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.
NCPDP Recommendations and Guidance for Standardizing the Dosing Designations on Prescription Container Labels of Oral Liquid Medications Version 1.0.
Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014.
This white paper describes recommendations to reduce risks around oral liquid medication administration, including assigning a standard unit of measure (milliliters), using leading zeroes before decimal points (for amounts smaller than one), and ensuring that dosing mechanisms and container labels employ corresponding units of measure.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.
Through a discussion of a vincristine administration error, this booklet and video illustrate how system weaknesses can contribute to failure.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
In: On the State of the Public Health: Annual Report of the Chief Medical Officer 2004. London, England: Department of Health; 2005.
This chapter analyzes compliance with National Health Service patient safety alerts, as outlined in An Organization with a Memory, in four risk areas and makes recommendations for improving compliance.
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.