AHRQ Patient Safety Network ► NEWSPAPER/MAGAZINE ARTICLE

AHRQ Patient Safety Network

NEWSPAPER/MAGAZINE ARTICLE

Newspaper/Magazine Article

24-Hour inpatient pulse oximetry monitoring reduces rescue events and intensive care unit transfers.

Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.

Hazards tied to medical records rush.

Rowland C. Boston Globe. July 20, 2014.

With oral chemotherapy, we simply must do better!

ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.

With oral chemotherapy, we simply must do better!

ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.

To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.

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Related Resources

BOOK/REPORT

Fluorouracil Incident Root Cause Analysis Report.

Toronto, ON, Canada: Institute for Safe Medication Practices Canada. May 8, 2007.

COMMENTARY

Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process.

Aboumatar HJ, Winner L, Davis R, et al. Jt Comm J Qual Patient Saf. 2010;36:79-86, AP1-AP4.

NEWSPAPER/MAGAZINE ARTICLE

Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.

ISMP Medication Safety Alert! Acute Care Edition. March 8, 2012;17:1-3.

COMMENTARY

A performance improvement plan to increase nurse adherence to use of medication safety software.

Gavriloff C. J Pediatr Nurs. 2012;27:375-382.

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