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.
Towne S. WPRI. November 2, 2011.
This article reports on a software malfunction that caused prescription errors affecting patients discharged from several Rhode Island hospitals.
Neergaard L. San Francisco Chronicle; November 1, 2011:A6.
This newspaper article reports on an executive order directing the Food and Drug Administration to take steps to prevent and mitigate drug shortages.
Graham J, Dizikes C. Chicago Tribune. June 27, 2011.
This newspaper article reports on an order entry error that resulted in a 60-fold overdose and raised concerns about the safety of electronic medication data systems.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
ISMP Medication Safety Alert! Acute Care Edition. September 23, 2010;15,1-6.
This piece explores the effects of drug shortages on patient safety and provides examples of resulting near misses, errors, and adverse outcomes.
Dolan PL. American Medical News. July 19, 2010.
This news article reveals Leapfrog Group survey findings that more than 50% of computerized order entry systems do not trigger order error alerts as they should.
ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.
This piece describes reports of tubing misconnections and discusses upcoming standards for connectors that will prevent such errors.
ISMP Medication Safety Alert! Acute Care Edition. April 22, 2010;15:1-4.
This piece highlights common failures in root cause analysis (RCA) and explains how each undermines the effectiveness of the technique.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.
ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3.
This article describes an unintended consequence associated with a low-tech drug order distribution method and provides recommendations to minimize the potential for missing information.
Rein L. Washington Post. July 21, 2009:E1.
This news article reports on Washington, DC–area initiatives to track preventable patient injury and discusses strategies to hold hospitals accountable to reduce the number of avoidable incidents.
Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.
ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.
This article examines a case in which a health care professional faces criminal charges for a medication error. The piece discusses how criminalization of errors in health care could thwart broader efforts to learn from mistakes.
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.
US News & World Report. July 3, 2008.
This article discusses the findings of a recent study that reported deficiencies in barcode systems requiring numerous overrides and "workarounds" by nurses.
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.
McCoy K, Brady E. USA Today. February 11, 2008:A1.
This series of investigative articles uncovers the factors involved in pharmacy errors, relates stories of patients harmed by such errors, and includes steps that consumers can take to minimize their risk.
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.
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. February 8, 2007;12:1-2.
This article discusses the problems associated with bypassing computer alerts and provides recommendations to improve alert systems.
ISMP Medication Safety Alert! Acute Care Edition. January 25, 2007;12:1.
This article discusses the weaknesses inherent in using the "five rights" for medication use as absolutes and suggests that they instead serve as broad goals to support safe medication practices.
Davies T. Washington Post. September 22, 2006.
This article reports on the deaths of three infants from heparin overdoses and describes how the hospital community has responded to the errors.
ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.
This second part of this series discusses the three types of behavior involved in error—human error, at-risk behavior, and reckless behavior—including causes of each and appropriate responses.
ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.
This article outlines systems failures that can contribute to the inadvertent misadministration of IV medications and provides several recommendations to support safe practices.
Gray R. Scotland on Sunday. January 8, 2006.
This story discusses the impact of a computer glitch in a system used by more than 80% of general practitioners in Scotland. In addition to physician notes being inadvertently attached to the wrong patient's medical record, reports suggest that some patients actually received incorrect prescriptions due to printing errors caused by the system.
Meisel Z. Slate. November 8, 2005.
In this article, an emergency medicine physician describes the work environment of emergency medical technicians and paramedics and why it is prone to error.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.