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- Communication Improvement 1
- Error Reporting and Analysis
- Legal and Policy Approaches 2
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 1
Search results for "Error Reporting"
- Error Reporting
Journal Article > Study
Mantri S, Fullard M, Gray SL, et al. JAMA Neurol. 2019;76:41-49.
This analysis of Medicare claims data found a significant prevalence of concurrent use of dementia medication with acetylcholinesterase inhibitors and anticholinergic medications. This medication combination is a frank medical error that the authors describe as a never event. Despite this, coprescription occurred in 44% of those prescribed dementia medication, and this medication error was more common in the southeastern and midwestern regions of the United States compared to the northeast or western regions.
Cases & Commentaries
- Spotlight Case
- Web M&M
Thomas H. Gallagher, MD; May 2011
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
Zarembo A. Los Angeles Times. October 15, 2009:A1.
This news piece describes communication gaps following a radiation overdose incident thought to involve more than 200 patients at one hospital.
Journal Article > Study
Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.
Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.
The investigators studied the type and number of medication errors before and after computerized prescriber order entry was implemented in an intensive care unit and found that medication errors increased initially.
FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.
Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; May 10, 2005.
In response to reports of injuries in patients with implanted neurological stimulators who underwent magnetic resonance imaging procedures, the Food and Drug Administration suggests related precautions for radiology personnel and physicians.