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Search results for "Monitoring Errors and Failures"
- Cognitive Errors ("Mistakes")
- Monitoring Errors and Failures
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.
Cases & Commentaries
- Web M&M
David N. Juurlink, BPhm, MD, PhD; July 2006
A patient presenting to the ED with chest pain was ruled out for MI, and discharged on an ACE inhibitor. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies.
Journal Article > Commentary
Miller LA. J Midwifery Womens Health. 2005;50:507-516.
The author presents a case analysis to illustrate common system errors in the use of intrapartum electronic fetal monitoring: inadequate knowledge, fear of conflict, and poor communication.