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Cases & Commentaries
- Web M&M
Hedy Cohen, RN, BSN, MS; February-March 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.
Journal Article > Commentary
Makic MBF. Clin Nurs Spec. 2015;29:195-197.
Smart pumps are considered a valuable method to improve medication safety. However, users may engage in workarounds that bypass the safety features of the equipment. This commentary relates risks and benefits associated with smart pumps and highlights opportunities to augment adoption and use of smart pump technology to prevent medication errors. A past AHRQ WebM&M perspective describes the value of smart pump technologies as a medication safety strategy.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.