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Journal Article > Commentary
Instituting vincristine minibag administration: an innovative strategy using simulation to enhance chemotherapy safety.
Corbitt N, Malick L, Nishioka J, Rigdon A, Szoch S, Torr P. J Infus Nurs. 2017;40:346-352.
Journal Article > Study
SIMMEON-Prep study: SIMulation of Medication Errors in ONcology: prevention of antineoplastic preparation errors.
Sarfati L, Ranchon F, Vantard N, et al. J Clin Pharm Ther. 2015;40:55-62.
This study examined error detection in chemotherapeutic preparation, which has been associated with several high-profile adverse outcomes. Pharmacy technicians were more likely to identify errors following a simulation exercise, adding to the evidence for simulation as an effective patient safety tool. A past AHRQ WebM&M perspective discussed a widely-publicized incident involving a patient who died due to inadvertent overdose of chemotherapy and the resulting organizational changes made in the hospital.
Cases & Commentaries
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.