Narrow Results Clear All
- Communication between Providers 9
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 4
- Human Factors Engineering 12
- Legal and Policy Approaches 8
- Logistical Approaches 3
- Policies and Operations 1
- Quality Improvement Strategies 13
- Specialization of Care 3
- Clinical Information Systems 5
- Transparency and Accountability 1
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 1
- Drug shortages 1
- Identification Errors 2
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events
- Psychological and Social Complications 1
- Second victims 1
- Transfusion Complications 1
- Internal Medicine 10
- Nursing 9
- Pharmacy 29
- Health Care Executives and Administrators 21
Health Care Providers
- Nurses 11
- Pharmacists 13
- Non-Health Care Professionals 6
- Patients 12
Search results for "Medication Errors/Preventable Adverse Drug Events"
ISMP Medication Safety Alert! Acute Care Edition. February 28, 2019;24.
Medication warnings inform providers and patients about risks associated with medication use. As with other safety strategies, applying a systems approach to medication warnings can help redirect actions and prevent patient harm. This article describes design, content, and language characteristics of successful medication safety warnings. In addition, specific design and user-centered considerations are included to improve the effectiveness of electronic alerting.
Porter S. HealthLeaders Media. April 26, 2018.
Overreliance on technology can result in harmful medication mistakes. Reporting on a 10-fold medication overdose that led to the death of a patient with dementia, this news article describes how the hospital changed their processes to improve medication safety, which included restructuring medication safety leadership, modifying the electronic health record to address alert overrides, and enhancing information sharing to support learning and transparency.
Roe S, King K. Chicago Tribune. February 10–13, 2016.
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age and use of medications for chronic conditions. This series of news reports discusses the problem of drug interactions, including one patient's experience of severe harm and researchers' use of data mining to identify medication pairs linked to high-risk interactions. The series also includes a list of steps patients can take to reduce risk of harmful interactions between medicines they take.
Brody JE. New York Times. November 30, 2015.
Karch AM. Am Nurs Today. September 2015;10:18-22.
The complexity of care delivery can hinder the role of nurses in preventing medication errors. This commentary advocates for updating the five rights to consider the patient's role in their medication therapy and to incorporate patient and family education into the process to improve medication safety.
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
Benchmarks tracking a wide spectrum of care activities enable comparison that can drive organizational commitment to improving safety. This newsletter article examines survey responses from nearly 400 hospitals which demonstrated modest progress in implementation of medication safety best practices that recommended strategies to augment safety, such as utilizing metric units as the only scale of measure for patient weight.
Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention.
Yang A, Grissinger M. PA-PSRS Patient Saf Advis. June 2013;10:41-49.
Blum K. Pharmacy Practice News. November 16, 2011.
Exploring the impact of medication errors on clinicians, this article discusses efforts to support second victims affected by medical error.
ISMP Medication Safety Alert! Acute Care Edition. February 9, 2011;16:1-3.
This piece discusses medication errors during emergency resuscitations and outlines risk-reduction strategies.
Anderson HJ. Health Data Manag. January 1, 2009;17:18.
Although shifting from paper-based or verbal orders to computerized physician order entry (CPOE) systems could reduce medical errors, a mere 8% of hospitals use the system and fewer implement it effectively, according to the Leapfrog Group CPOE evaluation tool.
ISMP Medication Safety Alert! Acute Care Edition. October 18, 2007;12:1-2.
Reporting on survey results that identified common errors that student nurses make, this article offers recommendations for both educators and students.
ISMP Medication Safety Alert! Acute Care Edition. February 22, 2007;12:1-3.
This article lists common risks associated with opiates, a high-alert medication, as well as recommended safety improvements to reduce these risks.
Brody JE. New York Times. January 2, 2007:F7.
This article discusses some common medication errors that consumers can avoid by asking the right questions and being familiar with prescriptions and the proper directions for taking them.
Santell JP. Drug Topics (Health-System Edition). May 22, 2006.
This article reports on errors involving neuromuscular blocking agents (NMBAs) that were reported to Medmarx database, what factors contributed to those errors, and what can be done to minimize their occurrence.
Wiley F. Drug Topics. August 2019;1633:16-18.
High-alert medications have the potential to cause serious patient harm if not administered correctly. Reporting on challenges to medication safety in the context of home, hospital, and cancer care, this news article recommends patient and health care professional education and support for collaboration with pharmacists as avenues for improvement.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors.
ISMP Safe Medicine. July/August 2015;13:1-3.
Dispensing errors in the community setting are a frequent source of concern. This newsletter article describes how correctly completed medication orders can inadvertently be given to the wrong patient in the community pharmacy setting and reviews steps patients can take to avoid receiving the incorrect medication.
ISMP Medication Safety Alert! Acute Care Edition. June 5, 2014;19:1-2,4-5.
Written numbers and letters that look alike can contribute to miscommunication in a variety of settings. This newsletter article provides examples of this issue in medication administration, discusses factors that increase risks, and recommends tactics to avoid confusion.
ISMP Medication Safety Alert! Acute Care Edition. May 22, 2014;19:1-2.
Errors occur frequently in vaccine administration when packaging instructions for diluents are unclear. This newsletter article offers recommendations for manufacturers and practitioners to reduce risks related to vaccines.
Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors.
ISMP Medication Safety Alert! Acute Care Edition. March 13, 2014;19:1-2,4-5.
Summarizing results from a national survey investigating vaccine administration errors, this article outlines recommendations to reduce risks associated with the use and packaging of vaccines. Tips include establishing protocols for commonly used vaccines, requiring periodic training for staff, and labeling prepared syringes.
Higgins J. Akron Beacon Journal. September 2, 2011.
This news article reports on a medication safety training program for staff in Ohio public schools.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
ISMP Medication Safety Alert! Acute Care Edition. October 22, 2009;14:1-3.
This report describes examples of mistaken administration of oral/enteral liquids through parenteral devices and provides strategies to prevent such errors.
Haiken M. Caring.com. August 17, 2009.
To help consumers use medications safely, this article describes 10 common medication mistakes and provides tips on how effective communication and clarification can prevent them.
Scott A. Drug Topics (Health-System Edition). November 10, 2008.
This article discusses hospital efforts to respond to the Joint Commission sentinel event alert regarding anticoagulants and highlights improvement strategies.
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.
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.
ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
This article reports on an overdose caused by improper label placement on a patient controlled analgesia (PCA) pump and provides recommendations for preventing pump-related medication errors.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
PA-PSRS Patient Saf Advis. June 2008;5:53-56.
This article reports on cases of improper IV administration of sterile water, a high-alert substance, for the treatment of hypernatremia and provides risk reduction strategies for this potentially fatal error.
Lin R-G II, Watanabe T. Los Angeles Times. November 22, 2007;A1.
This article reports on a non-fatal medication error that involved several neonates (including the newborn twins of actor Dennis Quaid) receiving a concentration of heparin 1000 times higher than intended. The discussion includes current hospital efforts to prevent medication errors and the growing interest in use of bar coding technology. A similar error captured headlines in 2006 when it caused the deaths of three infants.
Paul R. Drug Topics. September 17, 2007;151:10.
This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
This article analyzes a lethal error involving TPN (total parenteral nutrition), in which dosing and compounding were based on incorrect order entry, and provides recommendations to prevent similar errors.
ISMP Medication Safety Alert! Acute Care Edition. August 23, 2007;12:1-3.
This article discusses the myriad dosing methods that can lead to errors in administering intravenous medications and programming infusion pumps.
ISMP Medication Safety Alert! Acute Care Edition. June 28, 2007;12:1-3.
This article discusses inappropriate prescribing of medication patches for acute pain management and provides strategies for minimizing problems associated with their use.
Fernandez J. Drug Topics. May 7, 2007.
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken against the pharmacist involved.
Szabo L. USA Today. February 5, 2007.
This article suggests ways for patients to play a proactive and informed role in their own safe care. A video entitled "Things you should know before entering a hospital" accompanies the article.
Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.
This article reports on criminal charges brought against a nurse after she committed a medication error.
Foreman J. Los Angeles Times. September 4, 2006:F3.
This article describes what patients can do to minimize opportunities for medication error.
PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2.
This alert presents the risks involved with tablet splitting and outlines several recommendations for providers to increase safety.
Scalise D, Lazar C. Hosp Health Netw. May 2006:80:5,48,2.
The authors discuss the kinds of errors that occur in emergency departments and outline processes for minimizing their occurrence.
Manno MS. Nursing. 2006 Mar;36:56-61.
The author provides a comprehensive introduction to adverse drug events (ADEs), their impact, and strategies to prevent them. Nursing continuing education credits are available for the test on page 62.
PA-PSRS Patient Saf Advis. December 2005;2:29-31.
Using reports submitted to the Pennsylvania Patient Safety Reporting System, this advisory cautions against using unlabeled clear liquids and provides risk reduction strategies.
Chase M. Wall Street Journal. August 16, 2005:D1.
This article reports that in other countries, some medications have the same brand name as U.S. medications but contain completely different ingredients, often for treatment of different conditions. To avoid mix-ups, the article cautions against purchasing prescription medications abroad.