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- Specific to High-Risk Drugs
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
Journal Article > Review
Jones MR, Kaye AD, Manchikanti L, Hirsch JA. Curr Pain Headache Rep. 2018;22:20.
The opioid crisis requires multidisciplinary approaches to prevent misuse of pain medications. This review highlights the need for best practices to optimize the application of radiology expertise to address chronic noncancer pain, with an emphasis on low back pain. The authors suggest radiologists actively participate in developing pain assessment and management methods to help stem potential opioid misuse.
Journal Article > Commentary
Cohen M. Hosp Pharm. 2006;41:222-224.
This monthly selection of medication error reports provides examples of oral to IV dosing conflicts, name confusion with a new sleep aid, and radiology errors.