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Approach to Improving Safety
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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.
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.