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- Noncognitive Errors ("Slips & Lapses")
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Web Resource > Multi-use Website
Strategies for Ensuring the Safe Use of Insulin Pens in the Hospital.
American Society of Health-System Pharmacists.
Insulin is classified as a high-alert medication due to the potential to cause serious patient harm when administered incorrectly. This Web site provides information and resources related to an initiative aimed at augmenting pharmacist education about appropriate use of insulin and insulin pens in the hospital setting.
Tools/Toolkit > Fact Sheet/FAQs
Be an Active Member of Your Health Care Team.
Silver Spring, MD: US Food and Drug Administration; April 2014.
This fact sheet describes five ways patients can contribute to and ensure safe medication use, including speaking up about medical history, asking questions, and following directions on prescription labels. A question guide is also provided to help consumers become informed about their medications.
Web Resource > Multi-use Website
State-Wide Initiative to Standardize the Compounding of Oral Liquids in Pediatrics.
Michigan Pharmacists Association.
Children are often prescribed oral liquid medications due to difficulty swallowing tablets or capsules. This Web site provides resources for an initiative to standardize concentrations of pediatric oral liquid drugs to reduce inconsistencies that lead to medication errors.
Tools/Toolkit > Multi-use Website
MARQUIS Medication Reconciliation Resource Center.
Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). Philadelpha, PA: Society for Hospital Medicine.
This Web site provides resources to help hospitals implement medication reconciliation programs.
Newspaper/Magazine Article
Oral medications inadvertently given via the intravenous route.
Shah-Mohammadi AR, Gaunt MJ. PA-PSRS Patient Saf Advis. September 2013;10:85-91.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies incidents in which liquid oral medications were administered intravenously and recommends prevention strategies.
Newspaper/Magazine Article
Medication reconciliation meets its MATCH.
Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.
This newsletter article describes the development of the Medications at Transitions and Clinical Handoffs (MATCH) toolkit and relates one hospital's experience implementing it.
Special or Theme Issue
Handoff Communication Tools.
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
Web Resource > Multi-use Website
Aware in Care.
Miami, FL: National Parkinson Foundation; October 2012.
This Web site seeks to help hospitals and patients prevent medication errors in hospitalized patients with Parkinson disease.
Press Release/Announcement
Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 15, 2012.
This announcement reveals risks associated with administering codeine after a common pediatric procedure.
Web Resource > Multi-use Website
Tubing and Luer Misconnections: Preventing Dangerous Medical Errors.
US Food and Drug Administration.
This Web site provides information about tubing misconnections and how to prevent them.
Book/Report
A Review of FDA’s Approach to Medical Product Shortages.
Silver Spring, MD: US Food and Drug Administration; October 31, 2011.
This report outlines the complex nature of drug shortages and suggests strategies to augment the FDA's efforts to address them.
Audiovisual
Avoiding accidental overdoses when methadone is prescribed for pain.
Food and Drug Administration (FDA) Patient Safety News. Show #60. February 2007.
This video segment shares recommendations for providers about safe prescribing of methadone for pain control, including heightened patient monitoring and encouraging patients to ask questions about how the drug will affect them.
