U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
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ISMP medication error report analysis.
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.
Epidural-IV route mix-ups: reducing the risk of deadly errors.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
Medication safety initiative in reducing medication errors.
Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.
Bar code technology and medication administration error.
Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:696–698.
Effect of bar-code technology on the safety of medication administration.
Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.
Bar-code verification: reducing but not eliminating medication errors.
Henneman PL, Marquard JL, Fisher DL, et al. J Nurs Adm. 2012;42:562-566.
A clinical reminder about the safe use of insulin vials.
ISMP Medication Safety Alert! Acute Care Edition. February 21, 2013;18:1-3.
Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency.
Thomas AN, Panchagnula U. Anaesthesia. 2008;63:726-733.
Design for reliability: barcoded medication administration.
Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.
Administering a saline flush "site unseen" can lead to a wrong route error.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
2014–2015 Targeted Medication Safety Best Practices for Hospitals.
Horsham, PA: Institute for Safe Medication Practices.
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.
Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.
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.
Bar-Coded Medication Administration (BCMA).
Decisionmaker Brief. AHRQ Publication No: 08-0085, August 2008. Agency for Healthcare Research and Quality, Rockville, MD.
Shaping systems for better behavioral choices: lessons learned from a fatal medication error.
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
Medication administration quality and health information technology: a national study of US hospitals.
Appari A, Carian EK, Johnson ME, Anthony DL. J Am Med Inform Assoc. 2012;19:360-367.
Smart pump custom concentrations without hard "low concentration" alerts.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
ISMP Medication Safety Alert! April 8, 2010;15:1-3.
Bar-code technology for medication administration: medication errors and nurse satisfaction.
Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.
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