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Search results for "Active Errors"

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Journal Article > Commentary

Implementing smart infusion pumps with dose-error reduction software: real-world experiences.

Heron C. Br J Nurs. 2017;26:S13-S16.

Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.

Newspaper/Magazine Article

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

This news article reviews actual and potential medication errors submitted to the Institute for Safe Medication Practices in 2010 and provides recommendations to address them.

Journal Article > Study

Prevalence of medication administration errors in two medical units with automated prescription and dispensing.

Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-78.

Technological solutions such as computerized provider order entry (CPOE) hold promise for reducing medication errors at the prescribing and dispensing stage, but patients may still be harmed by incorrect administration of medications, which have been shown to be disturbingly common in prior studies. Conducted at an academic hospital in Spain that had an established CPOE system, this study found an overall administration error rate of 22%, consistent with prior studies. The hospital in question did not have a barcoding medication administration system. Combining barcoding with CPOE in a closed-loop system has been shown to significantly reduce the overall medication error rate.

Newspaper/Magazine Article

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

This piece identifies situations in which patient verification errors occur and provides strategies to address them.

Newspaper/Magazine Article

ISMP updates its list of drug name pairs with Tall man letters.

ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.

This article reports results of a national survey on how "tall man" lettering has clarified high-consequence drug name confusion and includes a list of medication name pairs in such lettering.

Journal Article > Study

Automated drug dispensing system reduces medication errors in an intensive care setting.

Chapuis C, Roustit M, Bal G, et al. Crit Care Med. 2010;38:2275-2281.

An automated drug dispensing system reduced medication errors at both the dispensing and administration steps in an adult intensive care unit.

Journal Article > Study

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

This study reports on a quality improvement effort to eliminate errors due to look-alike, sound-alike medications.

Cases & Commentaries

Double Dosing, by the Rules

  • Web M&M

Hedy Cohen, RN, BSN, MS; February-March 2009

New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.

Newspaper/Magazine Article

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.

Newspaper/Magazine Article

Medication errors associated with documented allergies.

PA-PSRS Patient Saf Advis. September 2008;5:75-80.

This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.

Newspaper/Magazine Article

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

This article describes dosing errors associated with improper concentration programming of patient controlled analgesia (PCA) pumps and provides recommendations for preventing future errors.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:618-621.

This monthly selection of medication error reports addresses examples of unclear dose preparation instructions, potential insulin storage mix ups, and drug name confusion.

Journal Article > Commentary

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

This article summarizes results from a conference regarding heparin errors, their epidemiology, and error types along with ways to increase safety.

Journal Article > Study

Dispensing errors in community pharmacy: perceived influence of sociotechnical factors.

Szeinbach S, Seoane-Vazquez E, Parekh A, Herderick M. Int J Qual Health Care. 2007;19:203-09.

Medication errors may originate at each step of the prescribing process, and a prior study conducted in the inpatient setting demonstrated that nearly 4% of medication orders may be dispensed incorrectly. In this study, community pharmacists were surveyed regarding their perceptions of the frequency of dispensing errors and factors contributing to errors. Respondents felt that dispensing errors were relatively frequent and were more likely when pharmacists were overworked, a sentiment supported by prior research. Bar coding has been advocated as one means of potentially reducing drug dispensing errors.

Cases & Commentaries

Cups of Error

  • Web M&M

Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN; May 2006

A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.

Cases & Commentaries

Workaround Error

  • Web M&M

Tess Pape, PhD, RN, CNOR; February 2006

Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.

Cases & Commentaries

40 of K

  • Web M&M

Timothy S. Lesar, PharmD; November 2003

An unclear verbal order leads to administration of the wrong drug.

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