Narrow Results Clear All
- Communication Improvement 2
- Education and Training 2
Human Factors Engineering
- Medical Device Design
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 2
- Alert fatigue 1
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Errors/Preventable Adverse Drug Events 6
Search results for "Medical Device Design"
- Hospital Pharmacy
- Medical Device Design
ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
This article reports on an overdose caused by improper label placement on a patient controlled analgesia (PCA) pump and provides recommendations for preventing pump-related medication 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.
Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Perspectives on Safety > Perspective
with commentary by Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN, Bar Coding for Medication Safety, September 2008
Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.
Gebhart F. Drug Topics (Health-System Edition). July 23, 2007.
This article describes how robust drug libraries developed for programmable smart pumps can help reduce medication errors associated with traditional infusion methods.
Information Exchange System Alert. Geneva, Switzerland: World Health Organization; July 18, 2007.
This international announcement provides guidance on the safe administration of the chemotherapeutic agent vincristine.
Health Manage Techol. April 2007;28:30-32, 34.
This article describes a health system's implementation of bar coding technology to support safe medication administration.