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- Error Reporting and Analysis 1
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- Quality Improvement Strategies 2
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- Device-related Complications 1
- Medication Errors/Preventable Adverse Drug Events 7
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Wahlberg D. Wisconsin State Journal. July 22, 2006:A1.
This article reports on a federal warning issued to a hospital after a medication error led to the death of a 16-year-old girl.
Fernandez J. Drug Topics. May 7, 2007.
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken against the pharmacist involved.
Paul R. Drug Topics. September 17, 2007;151:10.
This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.
Reporting that recalled medications were found in hospital pharmacies, this article describes recommendations to improve the process for removing recalled products.
Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.
This monthly selection of reports includes errors involving epidural medication administered intravenously and mistaken reuse of discontinued drugs.
ISMP Medication Safety Alert! Acute Care Edition. December 3, 2009;14:1-3.
This article discusses how a criminal prosecution has deeply affected an Ohio pharmacist who lost his license and is serving a prison sentence for failing to detect a medical error, which led to the death of a child.
Dembosky A. All Things Considered and KQED. January 23, 2019.
Policy, practice, and communication strategies have been implemented in an effort to stem the opioid crisis and prescribing activities that contribute to misuse. This news article and accompanying webcast discuss an initiative in California that sends letters to prescribers whose patients have died due to opioid overdose. The piece outlines unintended consequences associated with the practice, including clinician reluctance to prescribe opioids for pain. An Annual Perspective discussed the patient safety aspects of the opioid epidemic.