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Search results for "Dispensing Errors"
- Dispensing Errors
- Learning Organization
Journal Article > Study
Hassle in the dispensary: pilot study of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.
Sujan MA, Ingram C, McConkey T, Cross S, Cooke MW. BMJ Qual Saf. 2011;20:549-556.
In this study, qualitative interviews with frontline staff were used to identify sources of latent error within an inpatient pharmacy. The potential problems identified, which included issues with the work environment and information technology, were then prospectively monitored over a 6-month period. This process was used to design system improvements.
Cases & Commentaries
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- Web M&M
Patrice L. Spath, BA, RHIT; March 2007
An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.