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- WebM&M Cases 1
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Human Factors Engineering
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- Medication Safety 38
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Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Perspectives on Safety > Perspective
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
Web Resource > Multi-use Website
Human Factors Engineering Team, Center for Devices and Radiological Health, Office of Communication, Education, and Radiation Programs (OCER), Division of Device User Programs and Systems Analysis (DDUPSA), 1350 Piccard Drive, HFZ-230, Rockville, MD 20850.
Human factors engineering (HFE) helps improve human performance and reduce the risks associated with use error. The U.S. Food and Drug Administration (FDA) works with manufacturers to ensure the application of HFE in the design of new products. In addition to providing information on these design issues, this site facilitates the reporting of unsafe incidents with medical devices.
Casey SM. Santa Barbara, CA: Aegean Publishing Company; 1998. ISBN 13: 9780963617880.
This book introduces important human factors issues using a series of real cases and incidents from health care and a variety of other industries. The title refers to the disastrous death of a patient due to a design flaw in the radiotherapy accelerator, Therac-25. A plausible but unanticipated series of keystrokes by the operator resulted in the delivery of more than 100 times the intended dose of radiation. Other chapters discuss events as diverse as the Union Carbide disaster in Bhopal, India, an incorrect stock trade that nearly caused a market collapse, a variety of military and industrial examples, as well other cases from health care. The book provides numerous real-world examples of misadventures in human–system interactions.
King K. Silicon Valley/San Jose Business Journal. April 15, 2005: In Depth: Structures section.
The vice president of facilities at El Camino Hospital discusses the opportunity for building a facility that will improve patient care and employee productivity.
Bull G. USA Today. April 28, 2005.
This article reports on Target pharmacies' redesign of prescription bottles. The new bottles, designed to support safer outpatient medication use, have a flattened label and are color-coded for each family member.
Zipperer LA, Cushman S, eds. Chicago, IL: National Patient Safety Foundation; 2001. ISBN: 1579471889.
The editors present eight chapters covering key areas of patient safety: epidemiology of error, reporting of error, lessons from anesthesiology, emotional response to error, human factors, medication error, and general studies of error and administrative issues.
Hallinan JT. Post-Gazette.com. June 21, 2005.
This article summarizes the history of patient safety improvement in anesthesia and its impact on malpractice claims and costs within that specialty.
Kerber R. The Boston Globe. June 23, 2005;Business section:E1.
This article reports on problems with medical devices and discusses whether manufacturers should directly notify patients regarding defects.
Cohen B. "Morning Edition." National Public Radio. August 1, 2005.
This audio segment reports on a new prescription bottle that allows physicians and pharmacists to record verbal instructions, which patients can then retrieve by pushing a button on the bottle.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
McNeil DG Jr. New York Times. August 19, 2005;National Desk section:1.
This front page article in The New York Times reviews flying object incidents in magnetic resonance imaging (MRI) scanners. A number of dramatic cases are described (including several that were fatal), as are some of the challenges, both technological and procedural, in preventing this safety hazard.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; September 2010. AHRQ Publication No. 10-M052-C.
This 5-point checklist provides consumers with steps to help ensure the safety of their medication use.
Rockville, MD: Agency for Healthcare Research and Quality; December 2005.
This consumer video provides content complementary to the Agency for Healthcare Research and Quality checklist Check Your Medicines: Tips for Taking Medicines Safely.
Tools/Toolkit > Fact Sheet/FAQs
Vienna, VA: The Partnership for Safe Medicines; 2005.
This checklist will help patients determine if medications are possibly counterfeit, and it explains how to report problems.
Federal Register. April 10, 2006;71:18039-18053.
The U.S. Food and Drug Administration (FDA) is proposing to amend good manufacturing practice to include several strategies for minimizing medical gas-related patient safety incidents. The proposal is open for public comment through July 10, 2006.
Bernhard B. The Orange County Register. April 19, 2006.
This article reports on an Anaheim anesthesiologist's pre-surgery checklist, inspired by similar checklists used in the aviation industry.
Landro L. Wall Street Journal (Eastern edition). May 23, 2006:D1. [reprinted on Post-Gazette.com]
This article discusses the shared responsibility among patients, hospitals, and practitioners to support appropriate drug administration through medication reconciliation.
Fabregas L. Pittsburgh Tribune-Review. May 19, 2006.
This article reports on a system implemented at two hospitals that allows patients or families to initiate a "code" when a patient's condition raises serious concerns.