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- Communication Improvement 1
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies
- Technologic Approaches
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 3
- Medication Safety 6
- Psychological and Social Complications 1
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Cases & Commentaries
- Web M&M
Tejal K. Gandhi, MD, MPH; October 2003
Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
Cases & Commentaries
- Web M&M
Robert J. Weber, MS, RPh; May 2006
A pharmacist mistakenly dispenses Polycitra instead of Bicitra, and a patient winds up with severe hyperkalemia and hyperglycemia.
Tools/Toolkit > Toolkit
Pathways for Medication Safety Tool #2. Chicago, IL: American Hospital Association; 2003.
A compendium of risk assessment tools to assist in the prevention of medication errors. The tools emphasize the importance of a multidisciplinary approach to managing risk with key sections focusing on physicians, nurses, pharmacists, risk managers, and administrators.
Tools/Toolkit > Fact Sheet/FAQs
American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. July 2005;79:65-66.
This brief addresses the role of bar coding in medication safety and includes three case studies of implementation. It is the second in a series of six briefs focusing on medication errors.
Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.
Casey MM, Moscovice I, Davidson G. Upper Midwest Rural Health Research Center; December 2005.
The authors report the findings of a national study of small, rural hospitals in the United States. Results indicate a relationship between accreditation by the Joint Commission on Accreditation of Healthcare Organizations, financial status, pharmacy staffing, and technology use with the implementation of medication safety practices.
Davies T. Washington Post. September 22, 2006.
This article reports on the deaths of three infants from heparin overdoses and describes how the hospital community has responded to the errors.
Healthcare Quality Directorate, Department of Health. London, England: Crown Publishing; February 16, 2007.
This report discusses the impact that automated technologies, such as radio frequency identification (RFID) and barcoding, could have on health care in the United Kingdom and provides a plan to support their adoption in the National Health Service.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Improper insulin pen use is a persistent problem. This newsletter article reveals the lessons learned from one hospital that implemented best practices including robust education, bar-code scanning, bedside electronic medication administration records, and alerts to prevent incorrect administration but continued to experience errors related to insulin pen use.