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- Communication Improvement 1
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Logistical Approaches 1
- Technologic Approaches 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Interruptions and distractions 1
- Medication Safety
- Nonsurgical Procedural Complications 1
Search results for "Dispensing Errors"
- Critical Care
- Dispensing Errors
Cases & Commentaries
- Web M&M
Valentina Jelincic, RPh, and Julie Greenall, RPh, MHSc; February 2018
A hospitalized pediatric burn patient underwent dressing changes and burn inspection every third day. On those days she received oxycodone for pain, which allowed her to tolerate the painful procedures and to rest. After a dressing change one day, the mother noticed the child's breathing was shallow. That day the patient had received three doses of oxycodone, but because the automated dispensing machine had been stocked incorrectly with a higher concentration of oxycodone solution stored in the location normally reserved for the lower concention, she received nearly five times the dose ordered.
Journal Article > Review
Grundgeiger T, Sanderson P. Int J Med Inform. 2009;78:293-307.
This review article examined the impact of interruptions in critical care and medication dispensing settings.
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.
Journal Article > Study
Wheeler DW, Degnan BA, Sehmi JS, et al. Intensive Care Med. 2008;34:1441-1447.
This study found that errors frequently occurred when intravenous medications were prepared at the bedside, resulting in patients receiving incorrect doses of medications.