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- Communication Improvement 1
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Legal and Policy Approaches 1
Quality Improvement Strategies
- Specialization of Care 1
- Technologic Approaches 1
- Device-related Complications 1
- Identification Errors 1
- Medication Errors/Preventable Adverse Drug Events 9
- MRI safety 1
- Nonsurgical Procedural Complications 1
Search results for "Reminders"
Journal Article > Study
Lesar TS. Hosp Pharm. 2006;41:1053-1066.
Error in medication prescribing is a well-described problem in the hospital setting. This study sought to further characterize prescribing errors by determining the incidence of one specific type of error—errors in the route of administration. These errors were common, most frequently involving prescribing for the wrong route (eg, orally instead of intravenously), and cardiovascular drugs were most often implicated. The author provides suggestions for means of preventing these errors. A prior study by Lesar was one of the first to characterize the incidence of medication error in a teaching hospital setting, and he discusses the implications of error in the route of administration in a WebM&M commentary.
Tools/Toolkit > Government Resource
Huntington Valley, PA: Institute for Safe Medication Practices.
This Web site includes tools to help raise awareness about potential medication errors associated with using certain abbreviations. The tools are made available by Institute for Safe Medication Practices (ISMP) and U.S. Food and Drug Administration (FDA) as part of their national educational effort to eliminate the use of these abbreviations.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2006;11:1-2.
This article summarizes intravenous vincristine safety practices collected from more than 400 responses to a national online survey.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2005;10:1-2, 4.
This alert responds to fatal medication errors involving vincristine and reiterates the importance of adhering to error reduction strategies. The Institute for Safe Medication Practices is conducting a survey on administration of intravenous vincristine; the survey is included with this alert.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2005;40:940-945.
This monthly selection of medication error reports provides examples of problems with neuromuscular blocking agents, confusion with drug names, and unclear labeling practices.
Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.
This article reports on recommendations developed by United States Pharmacopeia (USP) to improve the safety of using medical gas, including revisions to USP monographs.
Journal Article > Commentary
Cohen MR. Hosp Pharm. 2005;40:844-847.
This monthly selection of medication error reports provides examples of drug misadministration, confusion with drug names, and administration of chemotherapy to the wrong patient, plus suggested United States adopted names for drugs.
Hall J. The Free Lance-Star. September 25, 2005.
This article presents one hospital's program to reduce the use of dangerous abbreviations. The hospital reports a significant reduction in inappropriate abbreviation use since launching their initiative.
Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued this alert to bring attention to a rare but potentially severe administration error reported with the cancer drug vincristine. A previous editorial discusses similar errors.
FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.
Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; May 10, 2005.
In response to reports of injuries in patients with implanted neurological stimulators who underwent magnetic resonance imaging procedures, the Food and Drug Administration suggests related precautions for radiology personnel and physicians.