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- Error Reporting and Analysis 3
- Legal and Policy Approaches 1
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- Medical Complications 1
- Medication Safety 2
- Psychological and Social Complications 1
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Cases & Commentaries
- Spotlight Case
- Web M&M
Abigail Zuger, MD; June 2011
An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Journal Article > Study
Ulanimo VM, O'Leary-Kelley C, Connolly PM. J Nurs Care Qual. 2007;22:28-33.
In this study, nurses at a Veterans Affairs hospital were surveyed regarding their experiences with medication errors and their perception of the effect of computerized physician order entry (CPOE) and bar code medication administration (BCMA) on the incidence of errors. Nurses identified many reasons for medication errors, including fatigue and illegible physician handwriting. While most nurses had filed an incident report due to a medication error, the majority agreed that some errors go unreported due to fear of criticism from management or colleagues. The implementation of CPOE and BCMA was associated with a lower perceived incidence of errors.
Journal Article > Commentary
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.