Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Error Reporting and Analysis 2
- Human Factors Engineering
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care
- Teamwork 1
- Clinical Information Systems 1
- Alert fatigue 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 4
- Nonsurgical Procedural Complications 1
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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.
Perspectives on Safety > Interview
Pharmacy and Safety, April 2006
Michael Cohen, RPh, MS, ScD, is president of the Institute for Safe Medication Practices (ISMP) and co-editor of ISMP Medication Safety Alert!, a biweekly newsletter. A pharmacist by training, his ground-breaking work and commitment to patient safety and preventing medication errors has spanned three decades. He received one of the prestigious MacArthur Fellowships (informally known as the "genius awards") in 2005.
Daner WE, Gosselin RC, Raschke R, Vanderveen T. Patient Saf Qual Healthcare. January/February 2009;6:20-25.
This article explains safety challenges commonly associated with heparin, a high-alert medication, and outlines how hospitals and clinicians can prevent these errors.
Journal Article > Study
Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.
Conducted by the American Society of Health-System Pharmacists (ASHP), this survey of more than 1300 pharmacy directors sought to evaluate the use of safety measures targeting medication dispensing and administration errors. Some positive signs were found in that use of proven technologies such as bar coding and smart infusion pumps has increased, but the overall proportion of hospitals using these technologies remains relatively low. Only a small proportion of hospitals had pharmacists attached to the emergency department (ED) or reviewed medication orders in the ED for errors. Prior surveys by the ASHP have examined the use of safety mechanisms for preventing prescribing and transcribing errors.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.