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Cases & Commentaries
- Web M&M
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
ISMP Medication Safety Alert! Acute Care Edition. November 14, 2013;18:1-4.
This newsletter article reports on concerns associated with chemotherapy preparations due to variations in concentration and recommends standardized preparation processes to address such risks.
Journal Article > Study
Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose."
Ching JM, Williams BL, Idemoto LM, Blackmore CC. Jt Comm J Qual Patient Saf. 2014;40:341-350.
This study highlights the use of Lean methodologies to facilitate implementation of barcode medication administration (BCMA) for hospitalized patients at Virginia Mason Medical Center. The introduction of BCMA led to significantly fewer medication errors. The concepts presented may be helpful for organizations employing new health technologies.
Journal Article > Study
Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study.
Seston EM, Ashcroft DM, Lamerton E, Harper L, Keers RN. BMC Health Serv Res. 2019;19:325.
This qualitative study evaluated a pharmacist technician–supported intervention to prevent errors of omission in medication administration. Most participants reported positive impacts of the intervention, but some pharmacy technicians failed to consistently observe nurses, citing feeling their presence was intrusive. Not all participants perceived the intervention as effective, leading to deviation from intended protocol. These findings highlight the challenge of implementing interventions across health care roles.