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- Error Reporting and Analysis 2
- Human Factors Engineering 5
- Legal and Policy Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 2
- Technologic Approaches 2
- Device-related Complications
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Safety
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
- Internal Medicine 3
- Pharmacy 2
Search results for "Anticoagulants"
- Device-related Complications
Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff.
Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food and Drug Administration. July 9, 2015;80:39440-39441.
Journal Article > Study
Shermock KM, Streiff MB, Pinto BL, Kraus P, Pronovost PJ. J Thromb Haemost. 2011;9:1769-1775.
In this study, investigators compared international normalized ratio measurements (INR, a measurement of blood clotting ability) obtained simultaneously on a point-of-care analyzer and a standard blood draw. Although the concordance between the two measurements met traditional quality assurance standards, the point-of-care analyzer results were systematically biased toward normal measurements, putting patients at risk of preventable adverse events due to failure to adjust anticoagulant medications appropriately.
ISMP Medication Safety Alert! Acute Care Edition. April 8, 2010;15:1-3.
Cases & Commentaries
- Web M&M
Tim Vanderveen, PharmD, MS; May 2009
Hospitalized for an elective procedure, a patient is given heparin in an incorrect concentration—off by a factor of 100.
Gould M. Health Service Journal. September 15, 2008:22-24.
This article describes the state of general practitioner incident reporting in the United Kingdom.
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.