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x Acetylcysteine (ORAL)
Acetylcysteine Oral Solution Mistaken for Parenteral Use (P&T)
Confusion between Acetylcysteine Dosage Forms (FDA video)
Drug Name Confusion: Mucomyst and Mucinex (FDA video)
MGH faces suit over drug error that killed woman - The Boston Globe

x Anticoagulants
MGH faces suit over drug error that killed woman - The Boston Globe
Preventing Errors Related to Commonly used Anticoagulants (TJC)

x Contrast (IV/Oral)

x D5W
Plain D5W or Hypotonic Saline Solns Could Result in Acute Hyponatremia

x Fentanyl Patches
Fentranyl Transd System: Taking Another Look (PA PSRS)

x Insulin
Action Needed to Drevent dangerous Heparin-Insulin confusion (ISMP)
Avoiding Med Errors with Insulin Therapy (CE 1.5 hr—
Complexity of Insulin Therapy (PA Pt Safety)
Considering Insulin Pens for Routine Hospital use? (ISMP)
Could U Be in Danger?: Insulin. The #1 Drug Error in Hosp (Diabetes Hea)
Cross Contamination with Insulin Pens (ISMP)
Eliminating insulin errors (Drug Topics)
High # of Dosing Errors with Insulin Products (Pt Safety Auth)
Insulin and Medication Errors (Pharm Times)
Insulin errors in hospital (Clinical Risk)
Insulin Errors: A Common Problem (CAPSLink)
Insulin Overdose Kills Nursing Home Resident : Blog
Insulin: Truly a High-Risk Medication (Pt Safety Solutions)
Med Errors Dosing of Insulin: Problems across the Cont (PA Pt Safety)
Misadventures in Insulin Therapy: J Natl Med Assoc 2-03
Overdoses Caused by Confusion Betw Insulin and TB Syr (PA Pt Safety)
Preventing Medication Errors (Diabetes in Control/ISMP)
Safe Use of Insulin -> True stories (NHS Diabetes)
Safer Administration of Insulin (NHS)
Special handling necessary to avoid insulin errors (Drug Topics)
Unintentional Therap Errors Involving Insulin (medscape/AnnPharmacother)

x Levothyroxine
A Point About Levothyroxine (Pharmacy Times)
Medication Errors Associated with Levothyroxine Products (ISMP)

x Narcotics, Opiods
Are Opioids Safe? (Medscape 1/11)

x Transdermal Patches
Transdermal Patches: High risk for error? (Drug Topics)

x Vaccines
Errors Involving Vaccines (CAPSLink)

x Vitamin D
Hypervitaminosis associated w/ Vit D dispensing error (Ann Pharmcother)

x Warfarin
Coumadin Admin and Monitoring Errors in the Nursing Home Setting
Medication Errrors — Warfarin (Clinical Practice Risk Mgmt)

x Water, Sterile
Sterile Water Should Not be Given
Warning on I.V. Infusions of Free Water (FDA video)
* Glossary (AHRQ Patient Safety Network)
* Safe Assessment Code Matrix and Triage Questions for Rt Cause Analysis
A Pharmacy Technician's Role in Med Error Prevention (Pharm Times)
Factors That Promote Effective Teamwork in Health Care (
Med Errors Are A Persistent Challenge (PharmPract News)
Med Errors: Causes, Prevention, Liability and the Apology_CE
Med Errors: Don't Let Them Happen to You (Am.NursToday)
Med Safety: Using Ext Errors to Uncover Potential Dangers (Pharm Times)
Medical Negligence Primer_2-22-11 (Amer Assoc for Justice)
Medication Errors: An FDA Perspective (CDER Forum slides)
Medication Errors: Prevention is the Key (CE 3 hr—
Patient Safety and the
Patient Saftey and the Just Culture: Primer for Heathcare Executives (mers-tm)
Pharmacy Practice for Techncians (google books)
Reduce Medication Errors associated with At-risk behavior (NCC MERP)
The RPh's Role in Reducing and Preventing Med Errors (
The Value of Close Calls in Improving Pt Safety (sample chapters)
To Err Is Human — report Brief (IOM 11-1999)
Top 10 Drug Errors and How To Prevent Them (medscape)
Value of Close Calls: Into Chapter (JCR)
We Have Newton on a Retainer:Reductionism When We Need Systems Thinking
When Is a Medical Error a Crime? (Wachter's World)

x Abbreviation Errors
Abbreviation Gotchas (PA Pt Safety) 2006
Abbreviation Gotchas (PA Pt Safety) 2007
Abbreviations: A Shortcut to Med Errors (PA Pt Safety)
Abbreviations—Help or Hindrance (CAPSLink)
Computerized Alerts Can Enhance Med Safety (media-newswire)
Drug Errors Caused by Abbreviations (FDA video)
Key to Compliance with JC Dangerous Abbreviatio List (ISMP 2004)
Medication Errors related to potentially dangerous abbreviations (JC)
Saving Time, But at what Expense (CAPSLink)

x Alert Fatigue
Heed this warning! Don't miss important computer alerts (ISMP)

x Allergies—Miscellaneous
Egg or Soy Product—Diprivan

x Barcode Med Admin-assoc Errors
Med Errors Prevented by & Assoc with BCMA Technology (CAPSLink)

x Calculation Errors
Calculation Errors Involving Children (CAPSLink)

x Compounding Errors
Compounded Drug Prep Errors(CAPSLink)
Eric Cropp — Jail term
Jail Time for Medical Error: The Case of Eric Cropp (Wachter's World)

x Computer Processing Errors
Computer Entry Errors (CAPSLink)
Risk of Computer Entry Errors (CAPSLink)

x Connfirmation Bias
Combating Confirmation Bias : AJN The American Journal of Nursing
Confirmation Bias (
Confirmation Bias (

x Drug Monitoring

x Height and Weight
Med Errors: Significance of Accurate Patient Weights (PA Pt Safety)
Vulnerability of e-prescribing Systems: Height & Weight Mix-up (ISMP CA)

x Drug Shortage Errors
Drug Shortages Affect Patient Safety (CAPSLink)

x Inattentional Blindness
7 Dumb Things We Do And 8 Tricks To Keep Errors at Bay | The Best Article Every
Effects of Individual Differences and Task Difficulty on Inattentional Blindness
Heed This Warning! Don't Miss Important Computer Alerts (ISMP)
Inattentional blindness: What captures your attention? (ISMP)
Journeys in Safety: Inattentional Blindness (Medscape)
Lessons learned from a fatal medication error:(
Med Errors: Don't Let Then Happen to You (Am.NurseToday)
Shaping Systems: Lessons Learned from a Fatal Med Error (TJC)
Visual Expert Human Factors: Inattentional Blindness & Conspicuity (M Green)

x Look-alike/Sound-Alike Errors
Look-alike Sound-alike Medications Errors (PharmLetter)
Look-alike/Sound-alike Drug Products Affect Cognition (CAPSLink)

x Medication Reconciliation
Conducting Med Rec at Various Patient settings
Getting Started Kit_ Med Rec
Making the Case # 1 (Northwestern MH)
Making the Case # 2 (Northwestern MH)
Making the Case # 3 (Northwestern MH)
Making the Case for Medication Reconciliation
MATCH - Assembling a Design Team and Developing a Med Rec Char
Med Errors due to Reconciliation Failures (CAPSLink)
Med Rec Practical Strategies and Tools (HRPro)
Using Medication Reconciliation to Prevent Errors (JC)

x Patient Identification Errors
Improving Patient Identification (CAPSLink)
Pharmacy Error Gives Pregnant Woman Abortion Drug (Injury Board)
Pregnant Colorado Woman Gets Abortion Drug ( ABC News)
Wrong Patient Errors (CAPSLink)

x Substitution Errors

x Workarounds
Workarounds in the Medication Use Process (ComputerTalk for the Pharmacist)

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Last updated :- 05:42 04-25-2012 EST

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