Narrow Results Clear All
Approach to Improving Safety
Safety Target
Clinical Area
Search results for "Hospital Pharmacy"
- Hospital Pharmacy
- Pharmacy
- Root Cause Analysis
Download Citation File:
- View: Basic | Expanded
- Sort: Best Match | Most Recent
Journal Article > Commentary
Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.
Graudins LV, Downey G, Bui T, Dooley MJ. Jt Comm J Qual Patient Saf. 2016;42:86-95.
Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.
Journal Article > Commentary
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:547-550, 554.
This monthly selection of medication error reports includes examples of errors due to drug labels and dosage as well as danger with look-alike, color-coded eye medications.
Newspaper/Magazine Article
Fluorouracil error ends tragically, but application of lessons learned will save lives.
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2007;12:1-3.
This article summarizes an incident involving chemotherapeutic agent overdose, describes factors contributing to the error, and provides recommendations for safer chemotherapy administration.
Book/Report
Fluorouracil Incident Root Cause Analysis Report.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
This report shares findings from a root cause analysis of a medication error incident that led to a patient's death. The report discusses systems failures that contributed to the event, as well as recommendations to improve safety.
Journal Article > Study
What’s past is prologue: organizational learning from a serious patient injury.
Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.
This case study examines an organizational response to a serious adverse event—a medication error in the intensive care unit that caused serious patient harm. Although a root cause analysis (RCA) was eventually convened, resulting in implementation of a systematic solution, prior to the RCA each professional group involved (nurses, pharmacists, and physicians) had already decided on individual approaches and solutions to the error. This resulted in unnecessary conflict and delays in reaching a workable solution to the problem.
Journal Article > Commentary
Developing a medication patient safety program — infrastructure and strategy.
Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.
The authors outline the practical considerations in developing a medication patient safety program, including establishing a blame-free environment and collecting and analyzing error data.
Cases & Commentaries
Caution, Interrupted
- Web M&M
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.