Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 5
- Legal and Policy Approaches 2
- Quality Improvement Strategies 4
- Technologic Approaches 5
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 3
- Medication Errors/Preventable Adverse Drug Events 9
- Nonsurgical Procedural Complications 2
- Second victims 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators 9
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 6
- Patients 1
Search results for "Medication Safety"
- Medication Safety
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
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.
Journal Article > Review
Jones MR, Kaye AD, Manchikanti L, Hirsch JA. Curr Pain Headache Rep. 2018;22:20.
The opioid crisis requires multidisciplinary approaches to prevent misuse of pain medications. This review highlights the need for best practices to optimize the application of radiology expertise to address chronic noncancer pain, with an emphasis on low back pain. The authors suggest radiologists actively participate in developing pain assessment and management methods to help stem potential opioid misuse.
Journal Article > Study
The impact of computerized provider order entry systems on medical-imaging services: a systematic review.
Georgiou A, Prgomet M, Markewycz A, Adams E, Westbrook JI. J Am Med Inform Assoc. 2011;18:335-340.
While most research on computerized provider order entry (CPOE) has focused on its role in preventing medication errors, CPOE—especially when combined with decision support—also has the potential to improve the quality and efficiency of care. This systematic review found that decision support systems (DSS) within CPOE increased adherence to radiology test ordering guidelines, resulting in an overall decrease in radiology utilization. These findings have the potential to improve patient safety as well, given the concern that unnecessary imaging studies may expose patients to dangerous levels of radiation. Prior studies have also shown that combining CPOE with DSS can improve diagnostic performance and encourage appropriate use of prophylactic medications.
Journal Article > Study
Enhancing pediatric safety: assessing and improving resident competency in life-threatening events with a computer-based interactive resuscitation tool.
Lerner C, Gaca AM, Frush DP, et al. Pediatr Radiol. 2009;39:703-709.
Use of a computerized interactive algorithm significantly improved residents' ability to correctly manage simulated cases of anaphylactic shock.
Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Journal Article > Commentary
Cohen M. Hosp Pharm. 2006;41:222-224.
This monthly selection of medication error reports provides examples of oral to IV dosing conflicts, name confusion with a new sleep aid, and radiology errors.
Stein R. The Washington Post. January 18, 2006:A03.
This article reports on an analysis of data collected by United States Pharmacopeia's voluntary reporting program that found medication errors are seven times more likely to occur during radiological procedures.
Cases & Commentaries
- Web M&M
Richard Cohan, MD; September 2004
Prior to a CT scan, a patient states that he is not allergic to x-ray dye. Soon after injection, he goes into anaphylactic shock.