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- Communication Improvement 4
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Quality Improvement Strategies 3
- Technologic Approaches 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors
- Medication Errors/Preventable Adverse Drug Events 3
- Surgical Complications 4
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Cases & Commentaries
- Web M&M
Kerm Henriksen, PhD; Kendall K. Hall, MD, MS; June 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
Journal Article > Commentary
AORN J. 2006;84:276-278, 280-283.
This guidance statement outlines recommendations from the Association of periOperative Registered Nurses (AORN) for developing, implementing, and evaluating safe medication practices in the perioperative environment.
Special or Theme Issue
AORN J. 2006;84(suppl 1):S1-S63.
This special issue includes a series of articles on SafetyNet, the Association of periOperative Registered Nurses (AORN) Web-based reporting system launched in 2004 as a part of its Patient Safety First initiative.
Association of PeriOperative Registered Nurses.
This survey will gather comments from the field regarding The Joint Commission's Universal Protocol to help eliminate wrong site surgeries.
Journal Article > Study
The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study.
Franklin BD, O'Grady K, Donyai P, Jacklin A, Barber N. Qual Saf Health Care. 2007;16:279-284.
Measures that have been proposed to reduce the incidence of medication errors target prescribing safety (e.g., computerized provider order entry) or safety in administering medications (e.g., bar coding or automated dispensing). While each of these individual measures has been shown to decrease errors, as yet few systems "close the loop" by integrating safety measures for prescribing and administering medications. Utilizing an electronic system that incorporated CPOE, automated dispensing, bar coding, and an electronic medication record, this single-institution study demonstrated a significant reduction in both prescribing errors and administration errors. However, staff time spent on medication-related tasks increased. While the study results are promising, one caveat is that the system was not used for high-risk drugs such as anticoagulants or intravenous medications.