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- Communication Improvement 1
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 3
- Legal and Policy Approaches 2
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 3
Search results for "Medication Errors/Preventable Adverse Drug Events"
- Cognitive Errors ("Mistakes")
- Medication Errors/Preventable Adverse Drug Events
- Neonatology and Intensive Care
Phend C. MedPage Today. November 26, 2007.
Within the context of a recent high-profile heparin error, this article reports on systems and protocols available to prevent medication errors. Interviews with three patient safety experts are available alongside the article via streaming audio.
Journal Article > Study
Reynolds TL, DeLucia PR, Esquibel KA, et al. JAMIA Open. 2019;2:49-61.
This pre–post mixed-methods implementation study examined a handheld decision support tool for nurses performing bedside administration of intravenous medications in intensive care units. Investigators found that though nurses desire decision support, the usability of the tool and fit with the critical care environment were suboptimal, leading to limited use. The authors suggest integrating mobile technology tools into existing infrastructure and developing user-informed implementation strategies.
"60 Minutes." CBS News Video. March 16, 2008.
This news video features an interview with Dennis and Kimberly Quaid discussing the dangers of medical errors in the context of a near fatal heparin overdose of their twin infants at Cedars-Sinai Medical Center.
Ornstein C. Los Angeles Times. December 5, 2007:B1.
This article discusses one couple's decision to hold a pharmaceutical company legally accountable for package and label designs they believe contributed to the heparin overdose of their twin infants.
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.
Ostrov BF. San Jose Mercury News. October 26, 2007;Local section:1B.
This article reports that, despite facing state sanctions and fines for its role in three fatal medication errors since 2004, a violating hospital was slow to retrain its pharmacy technicians.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2007.
This announcement describes a fatal overdose of a protease inhibitor in an infant and discusses how to prevent such occurrences.
Journal Article > Commentary
Miller LA. J Midwifery Womens Health. 2005;50:507-516.
The author presents a case analysis to illustrate common system errors in the use of intrapartum electronic fetal monitoring: inadequate knowledge, fear of conflict, and poor communication.