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Approach to Improving Safety
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Audiovisual
Preventing dosage errors with Diastat AcuDial.
Food and Drug Administration (FDA) Patient Safety News. Show #59. January 2007.
This video segment warns about potential dosing errors for an epileptic seizure treatment due to equipment design and provides instructions to minimize user error.
Journal Article > Government Resource
Infant deaths associated with cough and cold medications—two states, 2005.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2007;56:1-4.
The Centers for Disease Control and Prevention (CDC) investigated adverse events related to cough and cold medications in infants. The investigation found three instances in which these medications were considered the underlying cause of death.
Tools/Toolkit > Government Resource
ISMP and FDA campaign to eliminate use of error-prone abbreviations.
Huntington Valley, PA: Institute for Safe Medication Practices.
This Web site includes tools to help raise awareness about potential medication errors associated with using certain abbreviations. The tools are made available by Institute for Safe Medication Practices (ISMP) and U.S. Food and Drug Administration (FDA) as part of their national educational effort to eliminate the use of these abbreviations.
Press Release/Announcement
Consumers Filling U.S. Prescriptions Abroad May Get the Wrong Active Ingredient Because of Confusing Drug Names.
FDA Public Health Advisory [US Food and Drug Administration Web site]. January 2006.
This U.S. Food and Drug Administration advisory alerts clinicians and consumers to potential mistakes in prescriptions purchased abroad. The advisory includes a table of medications known to contain different active ingredients when purchased outside the United States.
Newspaper/Magazine Article
Drug name confusion: preventing medication errors.
Rados C. FDA Consum. 2005;39:35-37.
This article reports on problems with drug names, the naming process for medications, and both industry and consumer actions that can minimize misunderstandings.
Journal Article > Study
Implementing a commercial rule base as a medication order safety net.
Reichley RM, Seaton TL, Resetar E, et al. J Am Med Inform Assoc. 2005;12:383-389.
In this AHRQ-supported study, the investigators customized a commercial rule base to minimize nuisance alerts and improve alert specificity for overdosing.