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ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.
Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk.
Journal Article > Study
Chuo J, Lambert G, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:104-111.
The researchers analyzed intralipid medication error reports submitted to the Medmarx database and found that most errors occur in the administration phase and often involve smart pump delivery systems or evening shift change.
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.