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- Communication Improvement
- Culture of Safety 2
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 5
- Legal and Policy Approaches 2
- Clinical Information Systems 2
Search results for "Latent Errors"
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.
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.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
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.
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.
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.