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- Communication Improvement 2
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 1
- Quality Improvement Strategies 1
- Technologic Approaches
Search results for "Latent Errors"
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
Journal Article > Study
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
In this study, investigators identified possible medication errors using trigger tools, and a multidisciplinary team conducted real-time analyses to identify underlying system flaws contributing to the errors.
Cases & Commentaries
- Web M&M
Hedy Cohen, RN, BSN, MS; February-March 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.