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Search results for "Health Care Providers"
Journal Article > Study
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.
Bowdle TA, Jelacic S, Nair B, et al. Br J Anaesth. 2018;121:1338-1345.
This pre–post study of errors in anesthesia compared self-reported errors before and after implementation of a medication safety bundle that included smart infusion devices and barcode medication administration. Wrong-medication errors declined after barcoding was introduced, consistent with prior studies.
Journal Article > Study
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
Patient-controlled analgesia (PCA) is generally quite safe, but prior studies have shown that errors associated with PCA frequently result in patient harm. Due to several critical incidents associated with PCA errors, this Canadian hospital system implemented a multifaceted safety program including use of smart infusion pumps, standardized order sets, and mandatory error reporting. These interventions resulted in a significant reduction in PCA errors, chiefly by reducing pump programming errors (the most common type of error before the intervention). A PCA error with devastating clinical consequences is discussed in an AHRQ WebM&M commentary.
Cases & Commentaries
- Web M&M
Tim Vanderveen, PharmD, MS; May 2009
Hospitalized for an elective procedure, a patient is given heparin in an incorrect concentration—off by a factor of 100.
Journal Article > Commentary
Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].
Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.
The authors provide a case study involving patient-controlled analgesia (PCA) pump errors that contributed to an accidental morphine overdose. They discuss how the case illustrates that small mistakes can combine to create major problems.
ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.
This article outlines systems failures that can contribute to the inadvertent misadministration of IV medications and provides several recommendations to support safe practices.