U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Australia and New Zealand (1)
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Approach to Improving Safety
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Intravenous infusion safety technology: return on investment.
Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.
ISMP medication error report analysis.
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.
A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.
Tran M, Ciarkowski S, Wagner D, Stevenson JG. Jt Comm J Qual Patient Saf. 2012;38:112-119.
Misprogramming PCA concentration leads to dosing errors.
ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.
Smart pumps: advanced capabilities and continuous quality improvement.
Vanderveen T. Patient Saf Quality Healthc. January/February 2007.
The Role of Bar Coding and Smart Pumps in Safety
Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN AHRQ WebM&M [serial online]. September 2008.
Smart pump custom concentrations without hard "low concentration" alerts.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.
Smart pumps: implications for nurse leaders.
Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
ISMP Medication Safety Alert! April 8, 2010;15:1-3.
The rate and costs attributable to intravenous patient-controlled analgesia errors.
Meissner B, Nelson W, Hicks R, Sikirica V, Gagne J, Schein J. Hosp Pharm. 2009;44:312–324.
Are Two Insulin Pumps Better Than One?
Cook CB. AHRQ WebM&M [serial online]. January 2009.
Fluorouracil Incident Root Cause Analysis Report.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. May 8, 2007.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:960-964.
New technology, new errors: how to prime an upgrade of an insulin infusion pump.
Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.
Impact of a comprehensive safety initiative on patient-controlled analgesia errors.
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
Strategic work-arounds to accommodate new technology: the case of smart pumps in hospital care.
McAlearney AS, Vrontos J Jr, Schneider PJ, Curran CR, Czerwinski BS, Pedersen CA. J Patient Saf. 2007;3:75-81.
Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.
Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2014 Aug 12; [Epub ahead of print].
The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference.
Sanborn M, Gabay M, Moody ML. Hosp Pharm. 2009;44:159-164.
Errors during the preparation of drug infusions: a randomized controlled trial.
Adapa RM, Mani V, Murray LJ, et al. Br J Anaesth. 2012;109:729-734.
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