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Search results for "Monitoring Errors and Failures"
Cases & Commentaries
- Web M&M
Rodney W. Hicks, PhD, RN, FNP; February 2013
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Journal Article > Study
Kowiatek JG, Weber RJ, Skledar SJ, Frank S, DeVita M. Jt Comm J Qual Patient Saf. 2006;32:309-317.
This medication safety study describes a process to prevent unsafe medication dispensing from automated systems. Investigators evaluated the types and frequencies of medications administered by override, used an expert panel to revise the medication override list, developed a tool for override monitoring, and specifically measured the change in override use of opioids (a high-alert medication class). The authors discuss their multifaceted approach, present examples of the changes that resulted, and offer steps for other organizations interested in similar implementation strategies.