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Cases & Commentaries
- Spotlight Case
- Web M&M
Beth Devine, PharmD, MBA, PhD; April 2010
A medication dispensing error causes nausea, sweating, and irregular heartbeat in an elderly man with a history of cardiac arrhythmia. Investigation reveals that the patient was given thyroid replacement medication instead of antiarrhythmic medication.
Journal Article > Commentary
Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.
Singh R, Singh A, Fox C, Seldan Taylor J, Rosenthal T, Singh G. Inform Prim Care. 2005;13:135-144.
The authors describe a systems engineering model of analysis and synthesis for understanding error in ambulatory care settings.