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- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 5
- Human Factors Engineering 5
- Legal and Policy Approaches 4
- Quality Improvement Strategies 2
- Clinical Information Systems 1
- Transparency and Accountability 1
- Device-related Complications 2
- Diagnostic Errors 1
- Interruptions and distractions 1
- Medical Complications 2
- Medication Safety 7
- Nonsurgical Procedural Complications 2
Search results for "Canada"
- Newspaper/Magazine Article
Canadian Medical Protective Association. CMPA Perspective. September 2018;10:8-11.
Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.
SafeMedicineUse. August 19, 2015;6:1-2.
ISMP Canada. August 26, 2015;15:1-4.
Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. In response to an incident involving a chemotherapy administration error as a result of utilizing the incorrect infusion pump, this newsletter article discusses the development of a point-of-care checklist to assist in use of infusion pumps to improve safety.
Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.'
Blackwell T. National Post. January 16, 2015.
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
This newsletter article describes an incident involving a patient who noticed that the tablets in her prescription refill had a different marking than usual, alerting her that she might have received an incorrect medication which was confirmed by the pharmacist. Tips for patients to avoid medication errors include being familiar with how their medicines look and checking prescriptions before leaving the pharmacy. Practitioners can help prevent these errors by counting and labeling prescriptions one at a time and performing patient consultations.
Carville O. The Star. November 14, 2014.
This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and touches on the psychological impact of diagnostic error on the patient and his family. The potential causes of the mistake include laboratory sample confusion and misinterpretation of biopsy results.
Eggertson L. Can Nurse. March 2014;110:25-29.
Human factors engineering is being increasingly promoted as an approach that generates lasting safety improvements. This commentary describes how applying human factors principles can identify ways to reduce risks in health care settings, including issues related to interruptions and infusion pumps.
ISMP Medication Safety Alert! Acute Care Edition. February 27, 2014;19:1-4.
Summarizing results from a Canadian study to determine factors associated with fatal medication errors in the home, this newsletter article describes how patients and nonprofessional caregivers lacked understanding about their medication, such as potential adverse effects and signs of toxicity, which increased risk of harm.
ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.
This announcement reports on mistaken intravenous administration of breast milk and provides recommendations to prevent parenteral administration of enteral nutrition.
ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.
This article discusses a case of data entry error in an electronic prescribing system, explains the contributing factors, and provides recommendations to prevent such errors.
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.
Victoria Times Colonist. March 26, 2007.
This article reports on findings from an investigation into hospital-acquired infections in British Columbia.
Talaga T, Cribb R. Toronto Star. March 19, 2007.
This article discusses disclosure of medical errors and shares stories from several Canadian hospitals on their policies for disclosing adverse events.