Narrow Results Clear All
- Communication Improvement 11
- Culture of Safety 3
- Education and Training 7
- Error Reporting and Analysis 7
- Human Factors Engineering 16
- Legal and Policy Approaches 11
- Logistical Approaches 5
- Policies and Operations 1
- Quality Improvement Strategies 9
- Specialization of Care 1
- Clinical Information Systems 4
- Device-related Complications 8
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 5
- Identification Errors 2
- Interruptions and distractions 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 28
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
- Internal Medicine 7
- Surgery 1
- Nursing 7
- Pharmacy 23
- Family Members and Caregivers 2
- Health Care Executives and Administrators 28
Health Care Providers
- Nurses 4
- Non-Health Care Professionals 11
- Patients 13
Search results for "Latent Errors"
ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4.
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.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
ISMP Medication Safety Alert! Acute Care Edition. November 29, 2018;23:1-6.
Look-alike and sound-alike medications present a recurring threat to patient safety. This newsletter article summarizes an analysis of reported drug name confusion errors. Although incidents seem to have decreased over time, the influx of generic drug names is contributing to the persistence of the problem. Increased federal attention to the issue, provider use of known strategies to improve practice, and pharmaceutical company testing of names to avoid similarities can help reduce drug name confusion.
Mohr H, Weiss M. Associated Press. November 27, 2018.
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.
ISMP Medication Safety Alert! Acute Care Edition. October 9, 2014;19:1-5.
Changes in practice require time and monitoring to achieve lasting improvements. This newsletter article highlights issues that continue to hinder medication safety, including inconsistent availability of patient counseling, misuse of prefilled syringes, and disrespectful behavior toward both peers and patients.
Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2014;19:1-3,5-6.
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.
Eggertson L. Can Nurse. March 2014;110:25-29.
Human factors engineering is being increasingly promoted as an approach that generates lasting safety improvements. This commentary describes how applying human factors principles can identify ways to reduce risks in health care settings, including issues related to interruptions and infusion pumps.
Lefeber J. Patient Saf Qual Healthc. January/February 2014;11:26-28,30-31.
This article reveals the experience of a critical access hospital that used medication reconciliation to expand electronic health record adoption efforts. The author describes challenges hospital leaders faced and makes recommendations for organizations to consider when implementing a medication reconciliation program.
ISMP Medication Safety Alert! Acute Care Edition. 2014;19:1-3.
This newsletter article describes how changes in batch preparation processes can introduce opportunities for errors and suggests strategies to reduce such risks. Recommendations included providing visual alerts, limiting the amount of labels printed, and verifying labels before attaching them to the product.
Thomas K. New York Times. November 17, 2012:A1.
This newspaper article reports on the concerns of patients and health care workers associated with the continuing drug shortages in the United States.
Talsma J. Drug Topics. June 15, 2013.
Discussing the current state of and efforts to address drug shortages, this news article notes a reduction in chemotherapy delays and reveals persistent barriers to improvement.
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.
Tomsic M. WFAE Charlotte. National Public Radio. March 21–23, 2013.
This news series reports on the drug shortage problem, its impact on providers and patients, how it began, and concerns that wholesale companies are making it worse.
Murray C, Rycek W, Johnson D, Sifuentes-Tovar F. Pharm Purch Prod. January 2013;10:12.
This magazine article details how one academic medical center used a collaborative approach and implemented policies and procedures to address perioperative drug shortages.
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2012;17:1-4.
This newsletter article discusses results from a survey of community pharmacists on how time guarantees affect their practice.
ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.
This newsletter article highlights the importance of health care workers listening to and considering coworkers' concerns as behaviors that contribute to high reliability and patient safety.