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Search results for "Medication Safety"
Journal Article > Review
Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74:904-914.
Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.
Journal Article > Study
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
Patient-controlled analgesia (PCA) is generally quite safe, but prior studies have shown that errors associated with PCA frequently result in patient harm. Due to several critical incidents associated with PCA errors, this Canadian hospital system implemented a multifaceted safety program including use of smart infusion pumps, standardized order sets, and mandatory error reporting. These interventions resulted in a significant reduction in PCA errors, chiefly by reducing pump programming errors (the most common type of error before the intervention). A PCA error with devastating clinical consequences is discussed in an AHRQ WebM&M commentary.
Journal Article > Commentary
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].
Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.
The authors provide a case study involving patient-controlled analgesia (PCA) pump errors that contributed to an accidental morphine overdose. They discuss how the case illustrates that small mistakes can combine to create major problems.