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- Communication Improvement 1
- Education and Training 1
- Human Factors Engineering
- Quality Improvement Strategies 2
- Specialization of Care
- Teamwork 1
- Clinical Information Systems 1
- Alert fatigue 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 3
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Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.
Sipkoff M. Drug Topics (Health-System Edition). January 22, 2007.
This article spotlights two Philadelphia hospitals recognized for their innovative medication safety initiatives: use of color-coded storage bins and a venothromboembolism risk assessment form.
Journal Article > Commentary
Samaan KH, Dahlke M, Stover J. Am J Health Syst Pharm. 2011;68:63-68.
This commentary describes how a community hospital implemented a multi-component program to ensure that U-500 insulin was administered safely.