Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 2
- Education and Training 5
- Error Reporting and Analysis 2
- Human Factors Engineering 8
- Legal and Policy Approaches 4
- Logistical Approaches 2
- Policies and Operations 1
- Quality Improvement Strategies 6
- Technologic Approaches 11
- Device-related Complications 5
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Drug shortages 3
- Interruptions and distractions 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 17
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
- Health Care Executives and Administrators 15
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 5
- Patients 6
Search results for "Latent Errors"
ISMP Medication Safety Alert! Acute Care Edition. May 19, 2016;21:1-4.
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 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.
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.
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.
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. 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.
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.
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.
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.