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- Error Reporting and Analysis 1
Human Factors Engineering
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Search results for "Medical Device Design"
Cases & Commentaries
- Web M&M
Jill R. Scott-Cawiezell, RN, PhD; July 2008
An elderly man receiving feedings through a percutaneous enterostomy tube was prescribed intravenous total parenteral nutrition (TPN). A licensed practical nurse (LPN) mistakenly connected the TPN to the patient's enterostomy tube. His daughter (a retired nurse) asked her about it, and the RN on duty confirmed the error. The LPN disconnected the mistakenly placed (and now contaminated) line, but then prepared to attach it to the intravenous catheter. Luckily, both the patient's daughter and the RN were present and stopped her.
Journal Article > Commentary
Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.
This article summarizes results from a conference regarding heparin errors, their epidemiology, and error types along with ways to increase safety.