Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Error Reporting and Analysis 2
- Human Factors Engineering
- Specialization of Care
- Teamwork 1
- Clinical Information Systems 1
- Alert fatigue 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Errors/Preventable Adverse Drug Events 2
- 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.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.