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- Communication Improvement 2
- Education and Training 2
- Error Reporting and Analysis 1
Human Factors Engineering
- Policies and Operations 1
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 4
- Alert fatigue 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 3
Search results for "Checklists"
Journal Article > Study
Chemotherapy regimen checks performed by pharmacists contribute to safe administration of chemotherapy.
Suzuki S, Chan A, Nomura H, Johnson PE, Endo K, Saito S. J Oncol Pharm Pract. 2017;23:18-25.
Chemotherapy is known to be a high-risk treatment that requires specific safety protocols. This study found that pharmacy checks of physician chemotherapy orders entered via computer order entry do uncover errors. The authors conclude that electronic prescribing is not sufficient to ensure safe chemotherapy prescription and recommend maintaining the role of oncology pharmacists.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Journal Article > Review
'Why is there another person's name on my infusion bag?' Patient safety in chemotherapy care—a review of the literature.
Kullberg A, Larsen J, Sharp L. Eur J Oncol Nurs. 2013;17:228-235.
Cancer patients undergoing chemotherapy may be particularly vulnerable to medical errors, as their care often requires use of high-risk medications and must be closely coordinated between multiple physicians. This thematic review focused on methods to improve safety for chemotherapy patients and found evidence that computerized provider order entry could reduce medication errors. However, the authors did not find enough evidence to recommend other interventions that have been proposed, such as patient engagement or teamwork training for patients and families. An AHRQ WebM&M commentary discusses how one institution responded to a serious chemotherapy error.
Cases & Commentaries
- Web M&M
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Cases & Commentaries
- Web M&M
Richard Hellman, MD; March 2007
For a woman with insulin-dependent diabetes mellitus, the admitting medical team ordered sliding scale insulin. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the morning, the physician instituted a more appropriate insulin regimen.