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Medication errors are traditionally defined as an avoidable event, but they don't just happen during the prescribing phase. In fact, it's important to remember that there are many steps—transcribing, dispensing, and administering—where an error can occur. To learn more about pediatric medication errors specifically, we invited COPIC Patient Safety and Risk Manager, Kayla Boyd, to the podcast. In this episode, Kayla looks at the overall process of pediatric medication prescription, from diagnosis to accurate compilation of records to ongoing monitoring. Plus, you'll hear about ways to avoid adverse outcomes and mitigate risks with young children, appropriate ways to handle transfer of prescriptions, and continuing education to prevent mistakes. Feedback or episode ideas email the show at wnlpodcast@copic.comDisclaimer: Information provided in this podcast should not be relied upon for personal, medical, legal, or financial decisions and you should consult an appropriate professional for specific advice that pertains to your situation. Health care providers should exercise their professional judgment in connection with the provision of healthcare services. The information contained in this podcast is not intended to be, nor is it, a substitute for medical diagnosis, treatment, advice, or judgment relative to a patient's specific condition.
Can we significantly reduce pediatric medication errors in anesthesia care? This podcast episode explores the urgent need to address medication errors in pediatric anesthesia, highlighting effective strategies to improve patient safety. We discuss the implementation of tools such as the Anesthesia Medication Template, pre-filled syringes, and barcode scanning systems, as well as insights from experts on enhancing current practices.• Examination of medication error statistics in pediatric anesthesia• Discussion of the Anesthesia Medication Template (AMT) and its benefits• Overview of pre-filled syringes as a safety measure• Insights on challenges with pre-filled syringes • Evaluation of barcode scanning systems and their impact on safety• Expert opinions on future trends in medication safety• Emphasis on proactive strategies to prevent medication errors For healthcare professionals focused on refining patient safety, this episode is packed with practical insights and data-driven recommendations that could revolutionize your approach to pediatric care.For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/238-solutions-to-reduce-pediatric-medication-errors-during-anesthesia-care/© 2025, The Anesthesia Patient Safety Foundation
Unlock the secrets of preventing pediatric perioperative medication errors with insights from our esteemed guests, Eva Lu-Boettcher and Rahul Koka. Pediatric patients face unique challenges due to variations in body weight and dosing calculations, making them particularly vulnerable to medication errors. Join us as we explore the discrepancies between self-reported and observed error rates and gain a deeper understanding of the workflow vulnerabilities anesthesia professionals encounter. We also share findings from the Wake Up Safe Collaborative, revealing the administration phase as the most error-prone and illustrating how preventative and mitigative barriers can effectively manage risks through a bowtie analysis.Our commitment to enhancing patient safety doesn't end there. Discover the APSF Technology Education Initiatives, designed to equip anesthesia professionals with vital knowledge for safe practice. We highlight the Quantitative Neuromuscular Monitoring course, aligned with the ASA 2023 Practice Guidelines, as well as the importance of staying informed through courses on Low Flow Anesthesia and the upcoming Manual External Defibrillation, Cardioversion, and Pacing course. Our mission is to ensure that no one is harmed by anesthesia care, and this episode provides essential education and insights that every professional should incorporate into their practice.For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/237-preventing-pediatric-medication-errors/© 2025, The Anesthesia Patient Safety Foundation
How can we practice preventative healthcare?Joining from Canada this week is Lidia Molinara, a seasoned clinical pharmacist, CEO, patient safety officer, and fervent advocate for patient safety and effective communication within the healthcare system. Recalling her earliest experiences visiting pharmacies and the influence that has held on her clinical approach, Lidia encourages a deepening of the patient-physician dynamic - building good health and quality healthcare on advocacy, communication, and education.——We spoke about the importance of safety, some of the issues that are intrinsic to our use of medications, her personal experiences encountering medical issues, and some strong and easily applicable solutions traced out through her ACE framework.Follow me on Instagram and Facebook @ericfethkemd and checkout my website at www.EricFethkeMD.com. My brand new book, The Privilege of Caring, is out now on Amazon! https://www.amazon.com/dp/B0CP6H6QN4
Welcome to the second in our series of ‘The Aural Apothecary Analyses', where we will be delving a bit deeper into some of the recurring themes from our first series. This week we are joined by Dr Matthew Jones and Angela Carrinton to discuss medicines safety and how we can help clinicians & patients make better decisions. Healthcare professionals rely on guidelines to help them make the right choices. But do they work? Is the way we write and use guidance in practice actually harming patients? And what can we do about it? Join us as we discuss the balance between prescriptive guidance and the flexibility required to navigate complex systems, all while considering the critical role guidelines play in providing assurance and safety in healthcare.Angela will be well known to regular listeners, featuring as a guest in series 1. She is Lead Pharmacist for Medication Safety, Health and Social Care Northern Ireland and a Human Factors enthusiast. Mathew is a senior lecturer in medicines safety, medicines information and pharmaceutics at the University of Bath. He has coordinated the development of the South West Pharmacy Research Network and is the co-author of our discussion paper today - “Exploring the Role of Guidelines in Contributing to Medication Errors” https://pmc.ncbi.nlm.nih.gov/articles/PMC10954937/ In our discussion we dig into the role of guidelines and their real-world impact on patient care. From the pitfalls of laminating to the importance of user-testing, we explore how the design and writing of guidance can influence outcomes - sometimes with unintended consequences. Do digital systems actually make things better? Are guidelines themselves contributing to errors? And how can human factors expertise improve how clinicians interact with these tools in practice?As well as getting deep into the issue of medicines safety we also ask the important question - why on earth would anyone put mouthwash in a public toilet? Tune in to find out more on this important topic…As with all of our guests, Matthew shares with us his Memory Evoking Medicine, a career anthem and book that has influenced his career or life. Angela has already shared her choices in a previous episode which you can find our more about here where we discuss Medicines Safety in more detail and the World Health Organisations ‘Medicines Safety Challenge' https://www.theauralapothecary.com/episode-9-angela-carrington-the-world-health-organisations-medicines-safety-challenge/You can listen to the Aural Apothecary playlist here; https://open.spotify.com/playlist/3OsWj4w8sxsvuwR9zMXgn5?si=tiHXrQI7QsGtSQwPyz1KBg You can view the Aural Apothecary Library here; https://litalist.com/shelf/view-bookcase?publicId=KN6E3OOur website is https://www.theauralapothecary.com/ To get in touch follow us on Twitter and Instagram @auralapothecary or email us at auralapothecarypod@gmail.com . You can now also follow us on LinkedIn (https://www.linkedin.com/company/auralapothecary/) and BlueSKy @auralapothecary.pharmsky.app) Don't forget to rate us and comment wherever you get this podcast.
Part 1 In part one of this two-part series of Nurses Uncorked, Nurse Jessica and Nurse Erica welcome back Matthew, a registered nurse with a background in psychiatric nursing, home health care and wound care. They discuss the harsh realities in long-term care facilities, including regulatory compliance and the increasing use of non-clinicians in traditionally skilled nursing roles. The elder care industry is driven by profit, not patient welfare. Matthew shares his experiences and insights into the corruption and challenges faced in long-term care, which are often hidden from the public eye. The speakers delve into taboo issues such as no-CPR policies and 'do not send out' policies, the implications on patient rights, and the legal accountability of nursing staff. They highlight the dangers of medication administration by inadequately trained staff, the manipulation of regulations to maintain compliance, and alleged cover ups. In this conversation, the speakers discuss the alarming realities of long-term care facilities, highlighting tragic outcomes, the emotional toll on families. A comprehensive overhaul of the system is needed to ensure better care for seniors. Awareness of these issues is crucial for families considering long-term care. Thank you to our Enema Award Sponsor, Happy Bum Co. Please visit https://happybumco.com/ and use promo code NURSESUNCORKED for 15% off your first bundle. Thank you to our sponsor, Stink Balm Odor Blocker! Please visit https://www.stinkbalmodorblocker.com/ and use promo code UNCORKED15 for 15% off your purchase! Interested in Sponsoring the Show? Email with the subject NURSES UNCORKED SPONSOR to nursesuncorked@nursesuncorked.com Help Us Keep This Podcast going and become an official Patron of Nurses Uncorked! Gain early access to episodes, patron only bonus episodes, giveaways and earn the title of becoming either a Wine Cork, Wine Bottle, Decanter, Grand Preserve, or even a Vineyard member for exclusive benefits! Benefits also include patron only Zoom parties, newsletters, shout-outs, and much more. https://patron.podbean.com/nursesuncorkedpodcast Chapters 00:56 Introduction and Guest Welcome 02:54 Guest's Nursing Background 04:54 Cocktail of the Week 08:35 Regulations and Practices Differ Place to Place 12:25 Levels of Care in Long-term Care 16:00 COVID-19's Impact on Long-term Care 23:45 Med Techs and Directors of Wellness 26:34 The Taboo of Withholding CPR 34:28 Do Not Send Out Policies 41:07 Problem of the Week 46:20 Nursing Home Patient Death Ruled Homicide Due to Caregiver Neglect 56:45 Medication Errors and Cover-Ups 1:08:10 Enema of the Week Award Don't Miss Part 2 Next Week! Follow Matthew at: Tiktok: @themassholemcguido https://www.tiktok.com/@themassholemcguido?_t=8r5ukGBnvN1&_r=1 Erica's Merch/T-shirt: https://www.etsy.com/shop/TheNurseErica CPR Withheld Video: https://youtu.be/6O7DuIQ17SM?si=MSXFQXmOHbEziAJI National Donate Life Registry: https://registerme.org/ Cocktail of the Week: The Jessica Whiskey Sour: 1 Tbsp freshly squeezed lime juice 1Tbsp simple syrup Several splashes of Aromatic Bitters 1 1/2 oz (Kentucky Bourbon) Whiskey Shake in mixer and garnish with lime New episodes of Nurses Uncorked every Tuesday (Monday for patrons!). Help us grow by giving our episodes a download, follow, like the episodes and a 5 ⭐️ star rating! 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On episode 114 of PSQH: The Podcast, Lani Bertrand, Senior Director, Clinical Marketing & Thought Leadership at Omnicell, talks about how technology can help reduce medication errors.
Join us on the Anesthesia Patient Safety Podcast as we confront a critical patient safety issue: the recurring wrong drug, wrong route errors involving Tranexamic acid (TXA) and Bupivacaine. Elizabeth Rebello, an anesthesiologist at the University of Texas MD Anderson Cancer Center, sheds light on this alarming trend where lookalike vials lead to catastrophic outcomes, including paralysis and death. Learn why this issue demands urgent action and the steps that are essential for anesthesia professionals to prevent such devastating mistakes.We'll uncover real-world incidents and delve into the underlying challenges faced by anesthesia teams, from lack of standardization to high-pressure environments. Hear about the staggering 50% mortality rate associated with this error and revisit our previous coverage on a National Alert Network warning about similar TXA administration errors. This episode is a must-listen for those dedicated to advancing perioperative patient safety and mitigating the risks of medication administration errors in anesthesia care.For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/209-preventing-catastrophic-medication-errors-the-dangers-of-txa-and-bupivacaine-mix-ups/© 2024, The Anesthesia Patient Safety Foundation
Matt Grissinger, RPh, FISMP, FASCP is the Director of Education at the Institute for Safe Medication Practices (also known as ISMP). During our conversation, we talk about ISMP's Targeted Medication Safety Best Practices for Community Pharmacy first. Then, we talk about how to report an error, CPE available from past ISMP webinars, adding education on operations to the pharmacy school curriculum, and more. This is a great episode for any pharmacist, pharmacy student, pharmacy technician, or pharmacy owner. Medication Safety is important. Thank you for listening to episode 280 of The Pharmacist's Voice ® Podcast! To read the FULL show notes, visit https://www.thepharmacistsvoice.com/podcast. Select episode 280. Subscribe to or follow The Pharmacist's Voice ® Podcast to get each new episode delivered to your podcast player and YouTube every time a new one comes out! Apple Podcasts https://apple.co/42yqXOG Spotify https://spoti.fi/3qAk3uY Amazon/Audible https://adbl.co/43tM45P YouTube https://bit.ly/43Rnrjt Bio (May 2024) Matthew Grissinger, RPh, FISMP, FASCP is the Director of Education at the Institute for Safe Medication Practices (ISMP). He first joined ISMP in 2000 as an ISMP Safe Medication Management Fellow. Prior to joining ISMP, he served as a home care and long-term care pharmacy surveyor for the Joint Commission. He was project leader for the Hospital and Healthsystem Association of Pennsylvania (HAP) Hospital Improvement Innovation Network's (HIIN) Adverse Drug Event (ADE) Project, a collaborative project engaging healthcare organizations to reduce and prevent patient harm from the use of anticoagulants, insulins, and opioids. He has published numerous articles in the pharmacy literature, including regular columns in P&T and is a journal reviewer for a number of publications including the Joint Commission Journal on Quality and Patient Safety, Pharmacoepidemiology, Journal of Managed Care and Specialty Pharmacy, BMJ Quality and Drug Safety, and Annals of Internal Medicine. He is a chapter contributor to a textbook published by McGraw-Hill entitled Pharmacy Management: Essentials for All Practice Settings, Essentials of Nurse Informatics, Remington: The Science and Practice of Pharmacy, and Medication Errors. He is recently completed the Just Culture certification course. Mr. Grissinger serves as the Chair for the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), and Co-Chair of the National Quality Form (NQF) Common Formats Expert Panel. He is also on the Faculty Advisory Board for the Pharmacy Learning Network (PLN) and the Publications Advisory Board for Davis's Drug Guide for Nurses. He also served on the WHO Focus Group on Measurement Tools for Medication Safety, United States Pharmacopeia's (USP) Safe Medication Use Expert Committee from 2005-2010, the FDA Proprietary Name Review Concept Paper workshop panel in 2008, FDA Naming, Labeling, and Packaging Practices to Minimize Medication Errors workshop panel in 2010 and the Joint Commission Home Care Compounding Pharmacy Technical Advisory Panel in 2013. He is also an adjunct assistant professor for Temple University School of Pharmacy. Mr. Grissinger received a BS in Pharmacy from the Philadelphia College of Pharmacy and Science and is a fellow of the Institute for Safe Medication Practices as well as the American Society of Consultant Pharmacists. Subscribe to or follow The Pharmacist's Voice ® Podcast to get each new episode delivered to your podcast player and YouTube every time a new one comes out! Apple Podcasts https://apple.co/42yqXOG Spotify https://spoti.fi/3qAk3uY Amazon/Audible https://adbl.co/43tM45P YouTube https://bit.ly/43Rnrjt Links from this episode Matt Grissinger on LinkedIn https://www.linkedin.com/in/matthew-grissinger-63231ab/ ISMPs new website
Look-alike medicines, unclear communication and distractions during administration – medication errors may occur for many different reasons. They all have in common that they are unintended mistakes in the drug treatment process that may or may not lead to patient harm. In this episode Ghita Benabdallah and Loubna Alj from the national pharmacovigilance centre of Morocco, and Alem Zekarias from Uppsala Monitoring Centre discuss how we can prevent medication errors from occurring – and, when they do occur, make sure that they are reported as such. Tune in to find out:What are the most common causes for medication errors?How should strategies for preventing medication errors be devised? How does the assessment of suspected medication error reports differ from “regular” ADR signal assessment?What can be done to encourage healthcare professionals to report medication errors?Want to know more?In March 2024, WHO published this systematic review of the global burden of preventable medication-related harm in healthcare.According to this 2021 article in BMJ, an estimated 237 million medication errors occur in England every year. Avoidable adverse drug events were calculated to cost the National Health Service an annual sum of GBP 98 462 582 per year, consuming 181 626 bed-days, and causing/contributing to 1708 deaths. This 2012 meta-analysis confirmed what had been suggested in several observational studies: that preventable adverse drug reactions are a significant healthcare burden.The European Medicines Agency (EMA) has a dedicated webpage with recommendations, guidelines, legal requirements and a good practice guide on medication errors. Join the conversation on social mediaFollow us on X, LinkedIn, or Facebook and share your thoughts about the show with the hashtag #DrugSafetyMatters.Got a story to share?We're always looking for new content and interesting people to interview. If you have a great idea for a show, get in touch!About UMCRead more about Uppsala Monitoring Centre and how we work to advance medicines safety.
Join Drs Andrea Sikora and Christy Forehand in the discussion of their recent work with using a medication regimen complexity score to evaluate potential relationships between the score and medication errors in the ICU setting. What they found was surprising. What is to come with future research is exciting. Read the full article here.
In this Complex Care Journal Club podcast episode, Dr. Ulfat Shaikh discusses the development of an implementation toolkit to prevent medication errors in the home and community using quality improvement methodology. She describes the process of translating recommendations from a policy statement into practice, opportunities for collaboration with the Council on Quality Improvement and Patient Safety, and next steps from this work. SPEAKER Ulfat Shaikh, MD, MPH, MS Professor of Pediatrics and Medical Director for Healthcare Quality University of California Davis Health HOST Kristina Malik, MD Assistant Professor of Pediatrics, University of Colorado School of Medicine Medical Director, KidStreet Pediatrician, Special Care Clinic, Children's Hospital Colorado DATES Initial publication: March 11, 2024. JOURNAL CLUB ARTICLE Shaikh U, Kim JM, Yin SH. Implementing Strategies to Prevent Home Medication Administration Errors in Children With Medical Complexity. Clin Pediatr (Phila). 2023 Aug 29:99228231196750. doi: 10.1177/00099228231196750. Epub ahead of print. PMID: 37644803. OTHER ARTICLES REFERENCED Agency for Healthcare Research and Quality. Health Literacy Universal Precautions Toolkit, 3rd Edition. Use the Teach-Back Method: Tool 5. Content last reviewed February 2024. https://www.ahrq.gov/health-literacy/improve/precautions/tool5.html American Academy of Pediatrics Council on Quality Improvement and Patient Safety. Preventing home medication administration errors implementation resources. Published November/December 2021. Accessed August 16, 2023. bit.ly/44kK68W. Yin HS, Neuspiel DR, Paul IM, Franklin W, Tieder JS, Adirim T, Alvarez F, Brown JM, Bundy DG, Ferguson LE, Gleeson SP, Leu M, Mueller BU, Connor Phillips S, Quinonez RA, Rea C, Rinke ML, Shaikh U, Shiffman RN, Vickers Saarel E, Spencer Cockerham SP, Mack Walsh K, Jones B, Adler AC, Foster JH, Green TP, Houck CS, Laughon MM, Neville K, Reigart JR, Shenoi R, Sullivan JE, Van Den Anker JN, Verhoef PA. Preventing Home Medication Administration Errors. Pediatrics. 2021 Dec 1;148(6):e2021054666. doi: 10.1542/peds.2021-054666. PMID: 34851406. TRANSCRIPT https://op-docebo-images.s3.amazonaws.com/Transcripts/Preventing+Pediatric+Medication+Errors+at+Home_Shaikh_030824.pdf Clinicians across healthcare professions, advocates, researchers, and patients/families are all encouraged to engage and provide feedback! You can recommend an article for discussion using this form: https://forms.gle/Bdxb86Sw5qq1uFhW6 Please visit: http://www.openpediatrics.org OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children's Hospital and in collaboration with the World Federation of Pediatric Intensive and Critical Care Societies. It is designed to promote the exchange of knowledge between healthcare providers around the world caring for critically ill children in all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open access-and thus at no expense to the user.For further information on how to enroll, please email: openpediatrics@childrens.harvard.edu CITATION Shaikh U, Malik K. Preventing Pediatric Medication Errors at Home: Putting a Policy Statement into Practice. 3/2024. OPENPediatrics. Online Podcast. https://soundcloud.com/openpediatrics/preventing-pediatric-medication-errors-at-home-putting-a-policy-statement-into-practice
How do you influence the prescribing habits of an entire country? This is the task of NHS England's National Clinical Director of Prescribing Professor Tony Avery. We chat to Tony about this new, groundbreaking leadership role and techniques used to influence and improve prescribing practice across a whole nation. In addition to this role Tony is a practising GP, a professor of primary health care at the University of Nottingham and an NIHR Senior Investigator. In 2012, Tony and his team developed ‘Pharmacist-led Information Technology Intervention for Medication Errors' — or PINCER — project, which was rolled out nationally to general practices in England to tackle hazardous prescribing from 2018.In our micro-discussion, we talk about the recent Chief Medical Officer's annual report 2023: health in an ageing society https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2023-health-in-an-ageing-society Professor Chris Whitty's report recommends actions to improve quality of life for older adults and prioritise areas with the fastest growth in older people. We discuss the concept of ‘Lifespan vs Healthspan' and what that means for prescribing in an increasingly specialist medical model . As with all of our guests, Tony shares with us a Memory Evoking Medicine, a career anthem and book that has influenced his life. Be prepared for an Aural Apothecary first as Tony surprises us with his choice of song…Join us for our next live show in Bordeaux for the European Association of Hospital Pharmacists Congress! https://www.eahp.eu/congresses/programmeOur new website is now live https://www.theauralapothecary.com/ and as well as being a searchable database of all episodes, we will be uploading transcripts and extra content for your enjoyment and education. Have a look and let us know what you think! Our latest blog posts talks about our first live public show - ‘Music, Memories and Medicines' - have a read here; https://www.theauralapothecary.com/blog/the-three-apothecaries-music-medicines-and-memories/. To get in touch follow us on Twitter @auralapothecary or email us at auralapothecarypod@gmail.com . Don't forget to rate us and comment wherever you have got this podcast from. You can listen to the Aural Apothecary playlist here; https://open.spotify.com/playlist/3OsWj4w8sxsvuwR9zMXgn5?si=tiHXrQI7QsGtSQwPyz1KBg You can view the Aural Apothecary Library here; https://litalist.com/shelf/view-bookcase?publicId=KN6E3O
NASN School Nurse Editor, Catherine F. Yonkaitis, interviews authors Christy Giddens and Julie Blankenship about their article, "The Red Square: A Healthcare Sterile Cockpit to Reduce Medication Errors" which can currently be found in OnlineFirst. This article will be published in the March 2024 issue. To view the article, click here.
Have you ever felt overwhelmed by medication management in dementia care? Managing medications for a loved one with dementia can feel like navigating a labyrinth. This episode introduces a beacon of hope, PillMap, a simple yet ingenious solution to this complex challenge. Kimber Westmore, the founder of PillMap, has a career deeply rooted in fire life safety. Her passion for reducing medication errors was sparked by a personal mission to shield her parents from the risks of mis-medication. The inception of PillMap occurred at her family's kitchen table during Sunday dinners, born out of a desperate need to keep both family and paid caregivers well-informed. PillMap, known for its effectiveness, is now utilized in every state. It serves as a comprehensive guide to help with management of a pillbox and accompanies patients to various health-related appointments, including visits to doctors, pharmacies, and emergency rooms. Tragically, Kimber lost her husband to a heart attack 12 years ago. She is a mother to four children and a doting grandmother to four grandchildren. Her personal experiences and family-centric approach have been pivotal in shaping the compassionate vision behind PillMap. 0:04:09 Introducing Kimber and her product PillMap 0:09:14 The practicality and benefits of using PillMap 0:17:39 Simplifying Medication Instructions for Effective Communication 0:19:45 Pill Map: Lowering Medication Errors and Saving Lives 0:29:17 Challenges of the Healthcare System 0:30:46 Practical Improvements to the Product and Contact Information 0:32:28 Making Pill Map Locally 0:35:00 Continuing Support and Promotion for Pill Map 0:35:38 Pouring Heart and Soul into Serving Success Seekers You can find Kimber Westmore on: https://pillmap.com/ https://pillmap.com/product/pillmap-with-pen/ https://www.linkedin.com/in/kimber-westmore-a0603031/ https://www.facebook.com/PillMap Enjoy our podcast? Please take a moment to leave us a review on Apple Podcasts and Spotify —it really supports our show! https://podcasts.apple.com/us/podcast/dementia-caregiving-for-families/id1716187550 Get more information on how to help a parent living with dementia. Join our next free workshop. https://www.dementiacaregivingmadeeasy.com/wsl Join our Facebook Group at: https://www.facebook.com/groups/1301886810018410 Become a Founding Member of Our Exclusive Academy! Only 54 Founding Family Slots Available for Extraordinary Caregivers. https://www.dementiacaregivingmadeeasy.com/start
Dr. Laura Finn - BCGP, independent consultant pharmacist, Presenter at the ASCP 2023 Annual Meeting Dr. Scott Stewart: linkedin.com/in/scott-stewart-34973870 Dr. Tamara Ruggles: linkedin.com/in/tamara-ruggles-491882251 Institute for Safe Medication Practices: https://www.ismp.org/ Volume discrepancy of liquid controlled medications (page 348): https://www.cms.gov/files/document/r211soma.pdf
In this episode Mandy Atlee Allison, MD, MSPH, MEd, FAAP, a lead author on an updated policy statement on corporal punishment in schools, explains how pediatricians can advocate for patients and families. Hosts David Hill, MD, FAAP, and Joanna Parga-Belinkie, MD, FAAP, also speak with Natalie I. Rine, PharmD, BCPS, BCCCP, about her research on ADHD medication errors. For resources go to aap.org/podcast.
Thirteen vulnerable babies in the Countess of Chester Hospital neonatal ward fell victim to a series of horrifying crimes that shocked the medical community. Subjected to methods as cruel as air injections and insulin poisoning, their lives were put at grave risk. Joseph Scott Morgan and Dave Mack unravel the dark tale of Lucy Letby, the nurse responsible for these atrocities. They explore the systemic failures that allowed these crimes to go unnoticed, the role of autopsies in such cases, and the psychological aspects that might have driven Letby to commit these heinous acts that have forever changed the landscape of neonatal care Time codes: 00:00:00 — Joseph Scott Morgan opens the episode discussing the vulnerability of newborns and infants. 00:01:17 — Joe Scott introduces the term "neonates," explaining that these babies are even more susceptible to harm due to premature birth or physical issues. 00:01:42 — The conversation focuses on the case of Lucy Letby, a nurse who attacked 13 babies in the neonatal ward. 00:03:19 — Dave Mack notes that Lucy had specialized training for the neonatal unit. Her problems began almost as soon as she started working there. 00:04:00 — A brief history of the Countess of Chester Hospital is provided. Dave Mack points out that Lucy was the common denominator in all the cases. 00:09:03 — Joe Scott highlights the odd nature of the medication errors and the strict procedures for medication access. 00:10:44 — The methodology used in administering medication through an indwelling IV is discussed, providing insight into how Lucy could carry out her actions. 00:14:44 — Joe Scott talks about the usual procedures when a baby is in distress. He points out that the unexpected reactions of the babies could have raised suspicions. 00:15:37 — Joseph Scott Morgan discusses the role of autopsies in understanding deaths. He notes how this process can be compromised in cases involving premature babies. 00:17:04 — A description is provided of the chilling scenario of a neonatal unit to which a dangerous person has access. 00:20:00 — Joe details the lethal effects of air injections in the bloodstream and in feeding tubes, one of the methods Lucy used, causing immense pain and cardiac arrest. He talks about 00:24:17 — Dave Mack talks about the unexpected nature of a nurse being a killer. He also talks about the moment a mother discovers Lucy in the act. 00:28:00 — The damning evidence found at Lucy's home, including clinical notes and confessions, is discussed. 00:30:40 — Joseph Scott Morgan talks about the final three murders, including two brothers who were part of a set of triplets. He confirms that Lucy can be classified as a serial killer, pointing out the rarity of female serial killersSee omnystudio.com/listener for privacy information.
Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast is an exciting journey towards improved anesthesia patient safety.We are diving into the June 2023 APSF Newsletter today and talking about medication safety. Have you ever reached into your anesthesia drawer and grabbed a look-alike vial? This is a big threat to anesthesia patient safety. This is Part 1 of a two-part series on Look-alike and Sound-alike (LASA) drugs and medication errors.Additional sound effects from: Zapsplat.For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/156-medication-errors-related-to-look-alike-sound-alike-drugs/© 2023, The Anesthesia Patient Safety Foundation
Join us on this informative episode as we delve into the intricacies of the egg retrieval process in IVF. If you're preparing for your own egg retrieval, this episode is a must-listen. We guide you through each step, from the pre-procedure preparations to the post-retrieval recovery, ensuring you're well-prepared for the journey ahead.Tune in as we empower you with knowledge, offering a comprehensive guide on what to expect during your egg retrieval. By the end of this episode, you'll feel confident and well-informed, ready to embark on this significant step in your IVF journey.
This episode of ‘Inside Medical Malpractice' is the fourth in a series exploring the top 5 issues in medical malpractice: Assessment, Medication Errors, Communication, Unsafe Use of Equipment and Infection Control and Infection Control. Nova Scotia Lawyer Ray Wagner tackles the fascinating subject of Equipment Errors, which can result in individual malpractice cases or class action lawsuits. Specialized equipment is used all through the spectrum of healthcare delivery; to make the original diagnosis, decide on and provide correct treatment, to monitor and assist in a successful recovery, and in some cases, to sustain life. A product defect, maintenance or repair problem, or operator error, can lead to injury or even death. Listen in as Ray presents several cases from his own practice where the use of medical equipment or implants resulted in injury which led to lawsuits. He offers solid advice to healthcare providers and the public on how to avoid equipment errors and advice to lawyers considering litigating these tough cases. Don't miss this episode!
Happy EMS Week!!! PEC Journal Volume 27 Number 2 In this episode, the PEC podcast team brings you sprint podcast #2 of 3 for EMS week. This episode covers the Prehospital Emergency Care Journal Volume 27 Number 2. We talk about engaging manuscripts in this journal like: Medication Errors in Pediatric Patients after Implementation of a Field Guide with Volume-Based Dosing & Epidemiology and Prehospital Care of Pediatric Unintentional Injuries Among Countries with Different Economic Status in Asia: A Cross-National, Multi-Center Observational Study Click here to download it today! As always THANK YOU for listening. Hawnwan Philip Moy MD (@pecpodcast) Scott Goldberg MD, MPH (@EMS_Boston) Jeremiah Escajeda MD, MPH (@jerescajeda) Joelle Donofrio-Odmann DO (@PEMems) Maia Dorsett MD PhD (@maiadorsett) Lekshmi Kumar MD (@Gradymed1) Greg Muller DO (@DrMuller_DO)
Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast is an exciting journey towards improved anesthesia patient safety.Are you being smart when it comes to smart infusion pumps to help keep patients safe during anesthesia care? We are continuing the conversation about the intersection between anesthesia patient safety and technology on the show today. Join us as we discuss considerations for using smart infusion pumps during patient care.Additional sound effects from: Zapsplat.© 2023, The Anesthesia Patient Safety FoundationFor show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/146-a-smart-way-to-keep-patients-safe-from-medication-errors/
In this episode, we talk with patient safety advocate Dr. Ulfat Shaikh about preventing home medication errors.
Several studies have demonstrated the high frequency of medication errors in pediatric patients by prehospital providers during both patient care and simulation. Does the addition of a pediatric field guide improve the percentage of correct doses? Come join us at the next PCRF Journal Club to find out! Article: Medication Errors in Pediatric Patients after Implementation of a Field Guide with Volume-Based DosingAuthors: Lara D. Rappaport, Geoffrey Markowitz, Steven Hulac & Genie Roosevelt https://pubmed.ncbi.nlm.nih.gov/35020...To view the video, visit: https://www.youtube.com/watch?v=-lL5uzBbrDo&list=PLbmCpBsQ87iUYX9o_xvmC8x0mrV1G5B2d&index=3
This episode of ‘Inside Medical Malpractice' is the second in a five-part series exploring top issues in medical malpractice: Assessment, Medication Errors, Communication, Infection Control and Unsafe Use of Equipment. Repeat guest Paul Cahill tackles the tough subject of Medication Errors, which are so pervasive they make up 3 of the 15 “Never Events' in healthcare. There are 10 ‘rights' to medication administration which are considered basic knowledge for all healthcare providers. If followed correctly, these ‘rights' are meant to prevent errors. But listen in as Paul presents several cases from his own practice that involve nurses, doctors and pharmacists giving the wrong drug, or the wrong dose, at the wrong time, without any follow up. This episode offers solid advice to healthcare providers and the public on how to avoid medication errors, and Paul offers his own advice to lawyers who litigate these cases. Once again, the big take-away? Never, ever get complacent.
Across the world of health care, everyone is wrestling with how to reduce medication errors. With the decision in the Vanderbilt case, there is now the added fear of potential prosecution for giving an incorrect medication. Join the podcast crew as they try to better define the various types of medication errors while looking at what the literature says about medication errors in EMS. REFERENCES 1. Walker D, Moloney C, SueSee B, Sharples R, Blackman R, Long D, Hou XY. Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review. Prehosp Emerg Care. 2022 Jun 27:1-18. 2. Morrow D, North R, Wickens CD. Reducing and Mitigating Human Error in Medicine. Reviews of Human Factors and Ergonomics. 2005;1(1):254-296. 3. Hoyle JD Jr, Crowe RP, Bentley MA, Beltran G, Fales W. Pediatric Prehospital Medication Dosing Errors: A National Survey of Paramedics. Prehosp Emerg Care. 2017 Mar-Apr;21(2):185-191. 4. Misasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther Adv Drug Saf. 2019 Jan 21 5. Reason J. Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70.
This episode of ‘Inside Medical Malpractice' is the first of a five-part series exploring some of the top issues in malpractice; Assessment, Medication Errors, Communication, Infection Control and Unsafe Use of Equipment. Repeat guest Richard Halpern tackles the topic of Assessment, a skill considered fundamental for healthcare providers and a critical element of patient safety. Many malpractice cases include allegations that assessments weren't completed often enough, thoroughly enough, or at all. Listen in as Richard shares a case study on one of the most tragic and potentially under reported adverse events of all; a mother who dies from hemorrhaging after childbirth. The issues in this case are many, but the focus is on the lack of nursing and medical assessments in the early hours after the baby was born. The biggest takeaways from this episode? Stay vigilant. Remain diligent. Never, ever get complacent.
This month we invite Debra Tortora to our podcast as we welcome her into her new role of Risk Management and Legal Affairs at MedFlight/Medcare. While she is with us we cover the topic of "Medication Errors". Is this really a problem? What are the most common medication errors and how I can avoid them? What about securing medications, is that my responsible too? Can I be criminally charge for a medication error? We answer these questions and much more as we tackle this subject and discuss things we must do consistently to avoid this happening to us. Come listen in..
Drs. Bruce Lambert and Gordon Schiff share the less publicized details of the RaDonda Vaught medication error case, bringing to light nine steps for action to improve medication safety and ensure justice when errors occur. Access the full text manuscript for free at: https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/jac5.1676
Because medication errors account for a great number of patient deaths, a legal nurse consultant needs to be diligent in detecting their possible role in a medical malpractice case. Christine Dorman, critical care nurse practitioner, legal nurse consultant, and expert witness, shares with us her expertise in this area. After going through some basic clues that suggest medication errors, she goes into more detail. The administration of sedatives and paralytics requires close attention, as this is an area where errors may occur. Cardiac medication administration is another problematic area that calls for examination. For those who miss hand-written records, Christine emphasizes the value of electronic records for their programmed ability to detect a medication error. The biggest problem, though, is understaffing of personnel. Although the level of stress may have gone down from the height of the COVID pandemic, hospitals are still feeling the repercussions, especially since highly skilled personnel have retired or changed jobs due to burnout. Lack of communication can aggravate the situation, and Christine emphasizes the importance of accurately communicating essential information. Christine's ability to communicate her expertise makes this podcast highly informative and valuable. Be sure to take the opportunity to learn from her. Join me in this episode of Legal Nurse Podcast to learn about Catastrophic Critical Care Medication Errors - Christine Dorman What are clues that a medication error may have occurred in a patient's treatment? Why should special attention be paid to the administration of sedatives or paralytics? How do staffing shortages, such as occurred at the height of the pandemic, affect nursing care? Why is effective communication so vital? How does the use of electronic records help prevent medication errors? Listen to our podcasts or watch them using our app, Expert.edu, available at legalnursebusiness.com/expertedu. https://youtu.be/q6Q5rTZd3uc Join us for our 6th Virtual Conference LNC Success is a Livecast Virtual Conference 3-day event designed for legal nurse consultants just like you! It takes place October 27, 28, and 29, 2022. Pat Iyer and Barbara Levin put together THE first Legal Nurse Consulting Virtual Conference in July 2020. They are back with their 6th all-new conference based on what attendees said they'd find most valuable. This new implementation and networking event is designed for LNCs at any stage in their career. Build your expertise, attract higher-paying attorney clients, and take your business to the next level. After the LNC Success Virtual Conference, you will leave with clarity, confidence, and an effective step-by-step action plan that you can immediately implement in your business. Your Presenter of Catastrophic Critical Care Medication Errors - Christine Dorman Christine Dorman is the owner and lead nurse consultant for Vantage Point Legal Nurse Consulting (VPLNC). She has been a nurse for over 30 years. She began her career in 1991 as an LPN, became an RN in 1995, earned her BSN in 1999 from Florida International University, MSN with certification specialty as an ACNP (Acute Care Nurse Practitioner) from Barry University in 2005, and most recently obtained her DNP(Doctor of Nursing Practice) in Health Systems Executive Leadership from University of Pittsburgh in 2021. She has an extensive nursing background in med-surg, telemetry, pulmonary, trauma, adult critical care, and advance nursing practice. She currently works as a critical care nurse practitioner in Southeast, Florida. Connect with Christine https:www.vplnc.com
The Nursing Process and pharmacology, and Medication Errors
During the twentieth century, drugs were administered with much less care that in the current medical settings. Your host, Pat Iyer, recalls sometimes-fatal insulin shock therapy being administered to psychiatric patients. However, the rising number of deaths from medical and medication errors in the U. S. has made this crisis a significant issue, both in medical and legal arenas. Christine Dorman, a critical care nurse practitioner, has a doctorate and is a legal nurse consultant who specializes in critical issues. She brings her expertise to our discussion about how medication errors occur and how they can be prevented. She describes the many safeguards in place to ensure that the right medication is administered to the right patient, by the right route, at the right time, and at the right frequency. The participation of onsite critical care pharmacists further reduces the margin of error. Nonetheless, errors continue to occur. Christine and Pat discuss a Vanderbilt Hospital case wherein a nurse inadvertently administered a paralytic agent, Vercuronium, with tragic consequences. She also describes some other medicines that should be administered with great care and oversight. Knowing which drugs require the most attention and supervision helps an LNC in analyzing a medication errors case. In addition, Christine recommends checking dosages, patients' weights, the administration of antidotes. The LNC also needs to be or become familiar with the correct dosages and routes of delivery. Pharmaceutical companies continue to introduce new and diversified medications, a situation that makes their correct prescription and administration challenging for hospital and family medical practices. For you, as an LNC, this is an important area for learning. This podcast will help you learn more. Join me in this episode of Legal Nurse Podcast to learn about Critical Care Medication Errors with Christine Dorma How many people die annually due to medical errors? What are the five rights of the patient? How does an onsite critical care pharmacist help to prevent medicine errors? What ethical challenges do medical personnel face regarding self-reporting errors? How can an LNC investigate whether a medication error was made? Join us for our 6th Virtual Conference LNC Success is a Livecast Virtual Conference 2-day event designed for legal nurse consultants just like you! Pat Iyer and Barbara Levin put together THE first Legal Nurse Consulting Virtual Conference in July 2020. They are back with their 6th all new conference based on what attendees said they'd find most valuable. This new implementation and networking event is designed for LNCs at any stage in their career. Build your expertise, attract higher-paying attorney clients, and take your business to the next level. After the LNC Success Virtual Conference, you will leave with clarity, confidence, and an effective step-by-step action plan that you can immediately implement in your business. Your Presenter of Critical Care Medication Errors with Christine Dorma Christine Dorman is the owner and lead nurse consultant for Vantage Point Legal Nurse Consulting (VPLNC). She has been a nurse for over 30 years. She began her career in 1991 as an LPN, became an RN in 1995, earned her BSN in 1999 from Florida International University, MSN with certification specialty as an ACNP (Acute Care Nurse Practitioner) from Barry University in 2005, and most recently obtained her DNP(Doctor of Nursing Practice) in Health Systems Executive Leadership from University of Pittsburgh in 2021. She has an extensive nursing background in med-surg, telemetry, pulmonary, trauma, adult critical care, and advance nursing practice. She currently works as a critical care nurse practitioner in Southeast, Florida. Connect with Christine https:www.vplnc.com
In 2021, the 74th World Health Assembly adopted the Global Patient Safety Action Plan (GPSAP) 2021-2030 towards eliminating avoidable harm in healthcare. “Here in the United States, the Office of the Inspector General reports that one in four Medicare patients suffer harm in US hospitals,” says Sue Sheridan, a founding member of Patients for Patient Safety US, formed to advance this global plan in the United States. “Medication error is a huge global issue,” continues US founding member Soojin Jun in this interview with Mary Stober Murray (National Minority Quality Forum).
This is a short documentary about medication-related patient safety. The documentary explores and offers an overview of the current challenges and technical solutions related to medication safety to raise awareness about the need to further improve medication-related patient safety. Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at $42 billion USD annually. Errors can occur at different stages of the medication use process. More than 237 million medication errors are made every year in England, the avoidable consequences of which cost the NHS upwards of £98 million and more than 1700 lives every year, indicate national estimates, published online in the journal BMJ Quality & Safety. The documentary premiered on 29 June 2021. Watch the documentary and full interviews with the speakers: https://www.facesofdigitalhealth.com/overdose-documentary Learn more about Better Meds: https://meds.better.care/ Speakers in the movie and this episode: David W. Bates, Medical Director of Clinical and Quality Analysis, Information Systems, Patient Safety Expert and Harvard MD (Clinical & Research Perspective) Professor John Horn, PharmD, University of Washington School of Pharmacy, coauthor of “The Top 100 Drug Interactions”; A Guide to Patient Management” Martina Viduka, Practicing Nurse, Co-Founder of Advosense David Kliff, author and publisher of the Diabetic Investor eNewsletter, former investment advisor, and as a person living with diabetes (Patient Perspective) Duncan Cripps, Electronic Prescribing and Medication Management Lead at University Hospitals Plymouth NHS Trust (Pharmacist Perspective) Roni Shiloh, CEO of Seegnal, MD degree, specialized in Psychiatry (CDS provider and doctor perspective) Hicham Naim, Global Head Integrated & Personalized Patient Care Program, Digital Advisory Board at Takeda (Pharma Perspective) Marinka Žitnik, Assistant Professor of Biomedical Informatics, Harvard Medical School (Research perspective Lea Dias, Clinical Pharmacist, Founder and CEO of Quaefacta Abdulelah Alhawsawi, Ex - founding Director-General of the Saudi Patient Safety Center (SPSC) Roi Shternin, Founder of the patient-led Israeli society for Dysautonomia (Patient perspective).
In this episode we discuss a not so common issue, but one that does happen time to time. What to do if you missed a dose of your scheduled medication. Sometimes it can be disastrous, but most of the time it isn't. We discuss this topic and more.
The Institute for Safe Medication Practices (ISMP) has published the Top 10 list of frequently reported medication errors and hazards for 2021: https://bit.ly/3LZ5pSR. This episode delves into two key errors—COVID-19 vaccine-related errors and error reporting—and the implications of criminalizing medication errors on promoting a culture of safety in healthcare.
As a nurse, Medication errors are something you hope never happens, but what happens when they do happen? Join us this week as we chat with Trish Danyluk, a practicing registered nurse and psychiatric nursing instructor in BC. We'll be talking about the recent conviction of RaDonda Vaught, a nurse in Tennessee, who committed a fatal medication error, and what happens when medication errors are made. What does this case mean for nurses and medication errors regardless of the severity of the error and what does the impact this case have on nurses post-conviction and in Canada.
Christopher Jerry of the Emily Jerry Foundation shares the tragic story of an accidental medication error that took his daughter's life. Then, he takes us on a journey of working passionately through advocacy to be part of the solution to preventable medical errors through modification of internal systems, processes, and protocols in medicine. Learn more about the Emily Jerry Foundation at https://EmilyJerryFoundation.org/.
In this episode of Inside EMS, co-hosts Chris Cebollero and Kelly Grayson discuss a recent court case where a nurse was found guilty of criminally negligent homicide for a medication error that lead to the death of a patient. Chris and Kelly discuss the facts of the case and how the verdict could impact EMS. They also outline the steps providers should take to protect themselves when dispensing and administering medication on duty.
In today's episode of New Grad to ICU we talk about ways to practice safety with medication and how to help prevent medication errors. I have had quite a few nursing students and new grads reach out to me regarding the RaDonda Vaught Trial and express how they are now anxious to enter the workforce and have something similar happen to them. You all have the tools to help prevent errors like this from happening and hopefully listening to this episode will help you realize ways that you can practice safely. Reach out to me with any questions or concerns: @nursedoseofficial on Instagram. --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app
A 2010 study showed that 100% of nurses have made at least one mistake during their careers. In this video, I will share tips on how to prevent medication errors. Some links mentioned below are affiliate links.
A randomized controlled trial across 8 acute care hospitals showed that patients in the group that used Remote Patient Monitoring (RPM) after surgery, were 5.3% less likely to be readmitted, were 13.9% less likely to report pain 7 days after surgery, and were 24.2% safer because medication errors were detected. Hear from two leaders of this groundbreaking study: Dr Michael McGilion and Dr. PJ Devereaux from McMaster University. Find more great health IT content: https://www.healthcareittoday.com/
In this episode Carolyn Foster, MD, MSHS, FAAP, shares the latest research on how technology and remote patient monitoring are improving health outcomes. Hosts David Hill, MD, FAAP, and Joanna Parga-Belinkie, MD, FAAP, also talk to H. Shonna Yin, MD, MSc, FAAP, about the new AAP policy statement, Preventing Home Medication Administration Errors. For resources go to aap.org/podcast.
Come along with Jamie and Sarah as they review the listener responses to our most recent medication errors episode. Make sure you send YOUR feedback to our Instagram @nursecoffeetalk or our email nursecoffeetalk@gmail.com.
Medication Errors and How to Avoid Them – Episode 62, To Your Health with Dr. Jim Morrow On this edition of To Your Health, Dr. Jim Morrow shared a personal story about medication errors, and how patients can ensure they understand their medications to avoid errors which might cause serious health consequences. Dr. Morrow also […] The post Medication Errors and How to Avoid Them appeared first on Business RadioX ®.
This week's episode features Matthew Grissinger, a pharmacist and Director of Error Programs at ISMP - The Institute for Safe Medication Practices as he discusses what roles pharmacy technicians can take to help prevent medication errors. Grab your tickets for CPhT LIVE 2021 at https://www.cphtlive.com/ Become an NPTA member or upgrade your current membership at https://www.pharmacytechnician.org/npta/JoinRenew.asp
Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast is an exciting journey towards improved anesthesia patient safety. Be on the look-out for look-alike medication vials to help keep patients safe. Today, we are talking about the 7th APSF Patient Safety Priority, Medication Safety with exclusive content from the APSF Social Media Manager, Amy Pearson. Plus, we are diving back into the June 2021 APSF Newsletter to discuss Medication Errors and Hazards from 2021.© 2021, The Anesthesia Patient Safety FoundationFor show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/54-medication-safety-and-look-alike-vials/
100,000 medication errors are reported every year to the FDA. 400,000 drug-related injuries that happen every year in the hospital are because of medication errors, And 98,000 AMERICANS DIE ANNUALLY BECAUSE OF MEDICATION ERRORS. They can be prevented let's learn how. Text or call for more info 847-809-1214 check us out at www.AtYourRequestPatientAdvocate.netHit Like & subscribe if you like what you hear!
This week, Stacey is joined by Paul Pluta and Karen Zimm to discuss the particulars of the drug naming process, definitions, and categories for drug names. Karen and Paul present case study scenarios where drug name communications have led to adverse events. A drug may be known by different names during its development and commercial lifecycle. Medication safety problems associated with drug names have long been recognized as a significant problem by healthcare professionals. Whether it's look alike or sound alike errors, drug modifier misidentification, or proprietary vs. non-proprietary names, confusion may lead to medication errors – which of course can have fatal effects on patients and consumers. Resources for this Episode: Articles: Medication Safety: Industry Considerations Part 1 - Problem Overview https://www.ivtnetwork.com/article/medication-safety-industry-considerations-part-1-problem-overview Regulatory 101: Medication Safety - Industry Considerations, Part 2, Drug Names https://www.ivtnetwork.com/article/regulatory-101-medication-safety-industry-considerations-part-2-drug-names Regulatory 101: Drug Name Modifiers – Definition, Categories, Generics, And CAPA https://www.ivtnetwork.com/article/regulatory-101-drug-name-modifiers-%E2%80%93-definition-categories-generics-and-capa Regulatory 101: Biologic Non-Proprietary Drug Names – Terminology And Format https://www.ivtnetwork.com/article/regulatory-101-biologic-non-proprietary-drug-names-%E2%80%93-terminology-and-format Medication Safety And Drug Names - Valproic Acid Product Problems https://www.ivtnetwork.com/article/medication-safety-and-drug-names-valproic-acid-product-problems References: FDA. Guidance for Industry. Best Practices in Developing Proprietary Names for Drugs. https://www.fda.gov/media/88496/download FDA. Contents of a Complete Submission for the Evaluation of Proprietary Names. https://www.fda.gov/media/72144/download FDA. Safety Considerations for Product Design to Minimize Medication Errors. https://www.fda.gov/media/84903/download FDA. Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors. https://www.fda.gov/media/85879/download Medicines & Healthcare products Regulatory Agency (UK MHRA). MHRA Guideline for the Naming of Medicinal Products and Braille Requirements for Name on Label. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/810914/MHRA_Guideline_for_the_Naming_of_Medicinal_Products_and_Braille_Requirements_for_Name_on_Label.pdf.%C2%A0 European Medicines Agency (EMA). Guideline on the acceptability of names for human medicinal products processed through the centralized procedure. https://www.ema.europa.eu/en/documents/regulatory-procedural-guideline/guideline-acceptability-names-human-medicinal-products-processed-through-centralised-procedure_en.pdf. Health Canada. Guidance Document for Industry. Review of Drug Brand Names. https://www.canada.ca/en/health-canada/services/drugs-health-products/reports-publications/medeffect-canada/guidance-document-industry-review-drug-brand-names.html Health Product Regulatory Authority (Ireland). Guide to Invented Names of Human Medicines. file:///D:/HPRA%20Drug%20names.pdf. To Err is Human: Building a Safer Health System. Institute of Medicine, National Academic Press, Washington, DC, 2000. https://www.ncbi.nlm.nih.gov/books/NBK225182 Preventing Medication Errors. Institute of Medicine. National Academic Press., Washington, DC, 2007. https://www.nap.edu/catalog/11623/preventing-medication-errors Karen R. Zimm, Ph.D. Karen is currently an Associate Director in Global Regulatory Affairs for Johnson & Johnson Pharmaceutical Research and Development with responsibility for Chemistry Manufacturing & Controls for API's and marketed products. Previously she has held positions in technical operations with Pharmaceutical Sourcing Group – Americas, a division of Ortho-McNeil Pharmaceutical and research & development for the R.W. Johnson Pharmaceutical Research Institute and Whitehall Robins Healthcare (Wyeth Consumer Products). She earned her Bachelor of Science in Pharmacy and PhD in Pharmaceutics under Dr Joseph Schwartz from the Philadelphia College of Pharmacy and Science, MBA in Pharmaceutical Management from Drexel University, and the MS in Quality Assurance/Regulatory Affairs from Temple University. In addition she is a licensed pharmacist and an adjunct professor for the School of Pharmacy/Quality Assurance-Regulatory Affairs at Temple University in Philadelphia, PA. Paul L. Pluta, Ph.D. Paul is a pharmaceutical scientist with technical development, manufacturing, and management experience. He has been involved in nearly all phases of pharmaceutical development and manufacturing including R&D formulation and process development, dissolution, stability, regulatory, quality assurance/control, compliance, specifications, scale-up, technology transfer, technical support, and validation/qualification. In his time at Abbott he had numerous new product and supporting regulatory submissions, as well as, extensive product technical support experience. Additionally, his validation experience includes manufacturing process validation, cleaning validation, and associated systems qualification including aseptic systems. He was also a practicing pharmacist for many years in community and hospital environments with direct involvement in preventing medication errors. He may be reached at paul.pluta@comcast.net. Voices in Validation brings you the best in validation and compliance topics. Voices in Validation is brought to you by IVT Network, your expert source for life science regulatory knowledge. For more information on IVT Network, check out their website at http://ivtnetwork.com.
Today my guest is Pathologist Dr Brian Jackson. What we discuss with Dr Jackson: How studying mathematics led to medical informatics How he chose pathology as a specialty His research in physician utilization of laboratory tests Corporate social responsibility in healthcare Ethics as it applies to healthcare and laboratory testing How the Labmind Podcast came to be How he structures his interviews and some of the challenges of being a podcast host Links for this episode: Health Podcast Network LabVine Learning The ConfLab from LabVine Dress A Med scrubs LabMind Podcast ARUP Laboratories An Audit of Repeat Testing at an Academic Medical Center The Effect of Laboratory Test-Based Clinical Support Tools on Medication Errors and Adverse Drug Events People of Pathology Podcast: Website Twitter
Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at $42 billion USD annually. Errors can occur at different stages of the medication use process. This is the movie trailer, adopted for audio for a short documentary (OVER)DOSE, How can we prevent medication errors? which will air on 29 June 2021. More about the event: https://www.linkedin.com/events/over-dose-howcanwepreventmedica6800062280823263232/ Video trailer: https://www.youtube.com/watch?v=cPKvDYSm1mI&t=29s Speakers in this episode: David Kliff has been living with diabetes for over 20 years. He’s known as the Diabetic Investor, which is the name of the newsletter he’s been publishing for over two decades. Dr. David W. Bates, Professor of Health Policy and Management at Harvard T.H. Chan School of Public Health. Lea Dias is the founder of a healthcare startup called Quaefacta. She is a Clinical Pharmacist by background and in the past worked as the CLinical Safety Pharmacist at the Perth Children’s Hospital.
Dr. Dennis Boyle, COPIC physician risk manager, joins the podcast again to talk with Dr. Zacharias about ongoing issues we see with medication errors. These include drug-to-drug interactions, medications that are most prevalent in medical liability lawsuits (antibiotics, pain medicine, and anticoagulants), and awareness about black box warnings. Dr. Boyle walks through some case studies to illustrate why errors occur and highlights steps physicians can take to proactively address these situations. The conversation also covers the importance of documenting your thought process when prescribing, the use of “read backs,” the “five rights” of medication use (right patient, right drug, right time, right dose, and right route), the challenges of drug monitoring. Show Email: WNLpodcast@copic.com
Medication errors with vaccines can harm individual patients, but when they also undermine trust in public health programmes, serious problems can ripple across entire communities – as the Samoan healthcare crisis of 2018 dramatically showed. The Institute for Safe Medication Practices offers straightforward advice that could prevent those errors from happening again.This episode is part of the Uppsala Reports Long Reads series – the most topical stories from UMC’s pharmacovigilance magazine, brought to you in audio format. Find the original article here.Tune in to find out:which errors can occur in the vaccination processwhy two-component vaccines are especially susceptible to administration errorshow vaccine packaging and labelling can be improved to prevent errorsWant to know more?The Institute for Safe Medication Practices has repeatedly warned about the risks with two-component vaccines. In 2015, they issued a position statement calling for safer design of vaccine packaging and labelling.Tragic errors can occur when dangerous substances are accidentally used instead of the vaccine diluent, like the incident that occurred in Syria in 2014.The measles outbreak that took root in Samoa as a consequence of vaccine hesitancy – which in turn stemmed from an earlier, tragic vaccination error – holds important lessons for the rest of the world. Join the conversation on social mediaFollow us on Twitter, Facebook or LinkedIn, and share your thoughts about the show with the hashtag #DrugSafetyMatters.Got a story to share?We’re always looking for new content and interesting people to interview. If you have a great idea for a show, get in touch!About UMCRead more about Uppsala Monitoring Centre and how we work to make medicines safer for patients.
This episode is a continuation of the medication errors podcast from last week. In this episode, we continue to talk with Dr. Lauren Lobaugh, a pediatric anesthesiologist and discuss how she became interested in the field of patient safety and how anesthesiologists have been at the forefront of safe medication administration. We also discuss the scope of medication errors in modern medicine and how students, clinicians, and patients can prevent these errors.
In this episode, we talk with Dr. Lauren Lobaugh, a pediatric anesthesiologist, and discuss how she became interested in the field of patient safety and how anesthesiologists have been at the forefront of safe medication administration. We also discuss the scope of medication errors in modern medicine and how students, clinicians, and patients can prevent these errors.
We get behind the scenes with Katie for 2 juicy episodes! As a Nurse Practitioner, Speaker, Podcaster, Women’s Empowerment Activist talking all things Lifestyle, Career, and the Host of the Bad Decisions Podcast. Her podcast shares stories of struggle & success. She is an outspoken New Yorker pushing the boundaries in all areas of life. All of the taboo juicy topics such as Cancel Culture, Medication Errors, her experiences as a COVID provider & patient, Plastic surgery, and Burnout. She is a leader in speaking about owning your story, getting real with yourself & pushing through new industries! She is a Podcast & Instagram curator, has now (as of today, 2 scrub lines with Cherokee uniforms) and has developed a wildly popular workshop where she helps future entrepreneurs develop their brand. She really shifts the conversation to prove the importance of owning your failures which ultimately leads to success. Subscribe to Bad Decisions: https://podcasts.apple.com/us/podcast/bad-decisions/id1488035291 Bad Decisions Merch https://baddecisionspodcast.com/shop/ (https://baddecisionspodcast.com/shop/) Travel with Katie!!! https://www.trovatrip.com/trips/italy-with-katie-duke-nov-2021 (https://www.trovatrip.com/trips/italy-with-katie-duke-nov-2021) Shop Katie’s Scrubs https://www.infinityscrubs.com/thekatieduke (https://www.infinityscrubs.com/thekatieduke) To connect with Katie Duke click https://www.instagram.com/thekatieduke/ (HERE) Thank you to BetterHelp for sponsoring this episode! BETTERHELP: 10% off your first month when you take the quiz using the link below to get started! https://betterhelp.com/cellfie (https://betterhelp.com/cellfie) To connect with Nurse Tori click https://www.instagram.com/nurse.tori_/ (HERE) Read more on Tips From Tori Blog click https://www.tipsfromtori.com/ (HERE) Instagram: https://www.instagram.com/cellfie_podcast/ (@cellfiepodcast) Music: https://www.purple-planet.com/ (https://www.purple-planet.com)
We get behind the scenes with Katie for 2 juicy episodes! As a Nurse Practitioner, Speaker, Podcaster, Women’s Empowerment Activist talking all things Lifestyle, Career, and the Host of the Bad Decisions Podcast. Her podcast shares stories of struggle & success. She is an outspoken New Yorker pushing the boundaries in all areas of life. All of the taboo juicy topics such as Cancel Culture, Medication Errors, her experiences as a COVID provider & patient, Plastic surgery, and Burnout. She is a leader in speaking about owning your story, getting real with yourself & pushing through new industries! She is a Podcast & Instagram curator, has now (as of today, 2 scrub lines with Cherokee uniforms) and has developed a wildly popular workshop where she helps future entrepreneurs develop their brand. She really shifts the conversation to prove the importance of owning your failures which ultimately leads to success. Subscribe to Bad Decisions: https://podcasts.apple.com/us/podcast/bad-decisions/id1488035291 Bad Decisions Merch https://baddecisionspodcast.com/shop/ (https://baddecisionspodcast.com/shop/) Travel with Katie!!! https://www.trovatrip.com/trips/italy-with-katie-duke-nov-2021 (https://www.trovatrip.com/trips/italy-with-katie-duke-nov-2021) Shop Katie’s Scrubs https://www.infinityscrubs.com/thekatieduke (https://www.infinityscrubs.com/thekatieduke) To connect with Katie Duke click https://www.instagram.com/thekatieduke/ (HERE) ALMOND COW: Code: Tori ($15 Off) https://glnk.io/j33/nursetori (https://glnk.io/j33/nursetori) To connect with Nurse Tori click https://www.instagram.com/nurse.tori_/ (HERE) Read more on Tips From Tori Blog click https://www.tipsfromtori.com/ (HERE) Instagram: https://www.instagram.com/cellfie_podcast/ (@cellfiepodcast) Music: https://www.purple-planet.com/ (https://www.purple-planet.com)
Most healthcare providers have made medication errors, however, we can often be scared to fess up when it happens over fear of punitive consequences.In order to get to the root of the problem surrounding medication errors and why they happen, we need to feel more comfortable talking about them. So this week- I’m sharing with you a story about a medication error I made as an ER nurse.Connect with Katie:Instagram - https://www.instagram.com/thekatiedukeFacebook - https://www.facebook.com/thekatiedukeWebsite - https://www.katiedukeonline.com
As Nurses we are taught about medication administration, and the 5 rights. We are also taught to hold our nursing license in high regard. We as nurses should always strive to help and never harm our patients. Unfortunately, there are factors that can hinder proper medication administration and nursing judgement. Not all medical errors originate from nurses but come from doctors as well. Why do medical errors occur? There are several reasons, beginning with transcription difficulties to administration errors. We go over these in detail in this podcast. We also talk about the story of Kim Hiatt, and how medication errors can affect more than just the patient. Nurses are expected to use their “nursing judgement” for many situations that arise on the floor. Nurses must ask questions. Medications are used “off- label” for a variety of situations, however, it can still be evidence based data that has been proven to be safe and effective. If you don't know, you need to ask. It is estimated that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. If more healthcare workers actually reported errors and near misses, then data would be more reliable. With reliable data, systems could be put into place to help prevent errors in the future. Please visit our website for our show notes and references for this podcast. www.thenursingpostpodcast.com
Come along with Jamie and Sarah as they discuss medication errors. This can be a scary topic, but it is so important, since med pass is a primary responsibility of nurses. Give us your feedback on your own experiences. And don't forget to like us, share us, and subscribe to us!
Inside EMS: Preventing medication errors in EMS by EMS1 Podcasts
Denae, Vanessa, and "The Shaft" sit down with Rachel, a mother of two, music teacher, and a woman full of grace and strength. She shares a vast story of forgiveness -- her firstborn son was given five times the amount of Fentanyl after a routine medical procedure when he was nine months old. It was a miracle he survived. Rachel and Tom, her husband, demonstrated incredible grace towards the medical establishment and nurse, who made the error. As a result of their experience, this medical establishment changed its policy to pre-dilute medication for infants. Nurse training uses her son's case as an example. They are thankful his story is being used to help prevent this for other families. As always, we have our weekly check-in, we chat about Denae's "No Penetration September" and why Europe does not have public bathrooms. What do you do when you start your period in front of the Eiffel Tower? In this episode we talk about: European Toilet Tricks to Know Before You Go: https://www.ricksteves.com/travel-tips/health/toilet-tricks Flutophone and recorder: https://www.pinterest.com/pin/297026537896835082/ Why Identical Triplets Are Rarer Than You Think: https://www.sciencealert.com/here-s-why-identical-triplets-are-far-rarer-than-you-think Facts about Hypospadias: https://www.cdc.gov/ncbddd/birthdefects/hypospadias.html FDA: Working to Reduce Medication Errors: https://www.fda.gov/drugs/drug-information-consumers/working-reduce-medication-errors Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S.: https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us The report, Preventing Medication Errors, points out the staggering numbers associated with preventable drug-related injuries per year: 400,000 in hospitals—averaging more than one per day—800,000 in long-term care facilities and another 530,000 among Medicare patients in outpatient clinics. In all, the report’s authors estimate that at least 1.5 million people are harmed by errors involving prescription medications each year, adding that this is likely an underestimate (Read more: https://www.rn.com/Pages/ResourceDetails.aspx?id=3546) Subscribe today on any podcast listening app and leave a rating and review to let us know what you think! Your feedback makes our day. Connect with us on Facebook, Instagram, and Twitter! If email is your thing, send us a note at hello@atyourcervix.us Just a reminder, the purpose of this podcast is to educate and empower, it is no substitute for professional care by a doctor or other qualified medical professional. Guests who speak in this podcast express their own opinions, experience, and conclusions. If you have any specific questions about any medical matter, you should consult your doctor or another professional healthcare provider.
Did you know that one out of every two surgeries involves a medication error? Pat shares new findings and offers solutions. Guest, Morgan Gleason – a teenager with a rare disease shares how her health crisis allowed her to become a patient experience advocate and speaker.
Did you know that one out of every two surgeries involves a medication error? Pat shares new findings and offers solutions. Guest, Morgan Gleason – a teenager with a rare disease shares how her health crisis allowed her to become a patient experience advocate and speaker. For more patient safety tips and tools - visit http://www.speakupandstayalive.comThis show is broadcast on Talk 4 Radio (http://www.talk4radio.com/) on the Talk 4 Media Network (http://www.talk4media.com/).
Author: Rachel Brady, MD Educational Pearls: Medication errors are estimated to be the 3rd leading cause of death A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death About 50% are in the ordering/prescribing phase; 25-30% during administration phase. Overworked and distracted providers are the most common underlying reasons for medication error A 2017 study found 40% of ED nurses witnessed a medication error in the last year Editor’s Note: This is a reasonable counterpoint References Farag A, Blegen M, Gedney-Lose A, Lose D, Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. J Emerg Nurs. 2017 May;43(3):246-254. doi: 10.1016/j.jen.2016.10.015. Epub 2017 Mar 28. PubMed PMID: 28359712. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. PubMed PMID: 27143499. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
Guest Speaker Susan Howard, Pharmacist and Pharmacy Director shares her views on Medication Errors which is one of the biggest issues with nurses in healthcare. Susan also elaborates on the Antimicrobials Stewardship Program and seeking solutions to help expand the nurses knowledge along with the Interdisciplinary approach to decrease med erors. (A correction in interviewing where she is on episode 5 instead of 6).
This week the Friends of Flo team talks medication errors; how they happen, how to deal with them, and ethical considerations.
Dhineli Perera interviews Professor Amanda Wheeler about medication errors at transitions of care and how these can be avoided.
On this episode of Chicago Injury Alert, we look at how a nationwide opioid shortage has caused medication errors throughout hospitals. The post Medication Errors Are Higher Due To Opioid Shortage first appeared on Briskman Briskman & Greenberg.
On this episode of Chicago Injury Alert, we look at how a nationwide opioid shortage has caused medication errors throughout hospitals.
One promise of electronic medical records (EMRs) was to reduce medication errors. That may not have occurred since one type of error, illegible orders, has been replaced by another: Order sets may incorrectly match a patient and necessary treatments. In this JAMA Performance Improvement podcast, we review a case in which guideline-based care was incorporated into an order set, then the guideline changed but the order set did not, resulting in a post-STEMI patient receiving β-blockers when they were contraindicated. Interviewees included Arjun Gupta, MD, University of Texas Southwestern Medical Center, and Jennifer L. Rabaglia, MD, MSc, Parkland Health and Hospital System, Dallas, Texas. Learning Objectives: To understand the role of β-blocker treatment in patients with acute myocardial infarction; to understand how EMR order sets should be developed and maintained. https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2018.0845
Pediatric Grand Rounds for Wednesday, January 31, 2018 H. Shonna Yin, MD, MS. Associate Professor of Pediatrics and Population Health Departments of Pediatrics and Population Health NYU School of Medicine / Bellevue Hospital Center
Medication Errors in Pediatric Anesthesia: A Report from the Wake Up Safe Quality Improvement Initiative
A patient was admitted to the hospital and got three times their normal dose of phenytoin resulting in phenytoin toxicity and a long hospital stay. Analysis of the error revealed problems with hospital organization, supervision issues and having an environment that facilitates errors. Errors don’t occur simply because one clinician makes a mistake—rather they occur because the hospital system fails to prevent them. Related article: Phenytoin Toxicity—A Significant Adverse Drug Event
The terms ADE, ADR, and medication error are sometimes used interchangeably, but they are different and distinct By Chris BeebeDVP Medication Safety
Child Medication Errors. Have you ever checked your child’s medications to see if you’re giving them the right medicine? Of course you have. Have you ever checked your own ability to measure out the correct dose of medicine? Are you certain your measuring ability and the tools you’re using to measure the medications are accurate? […] The post Special Parents Confidential Episode 40 Child Medication Errors. appeared first on Special Parents Confidential.
William Zellmer speaks with Christy Gorbach and Kevin Garey about risk factors for pharmacists making medication errors during order verification. The article under discussion appears in the September 1, 2015, issue of AJHP. AJHP is the official journal of the American Society of Health-System Pharmacists. www.ajhpvoices.org
Medication errors are common with dosage errors being the most common. This month on the Chicago injury alert, we look at the different causes from prescription errors to pharmaceutical negligence.
Medication errors are common with dosage errors being the most common. This month on the Chicago injury alert, we look at the different causes from prescription errors to pharmaceutical negligence. The post Medication Errors by Pharmacists are More Common than Many Think – Podcast first appeared on Briskman Briskman & Greenberg.
Confusing heparin and insulin can have live threatening results. It might sound hard to do but think about all the similarities involved with the two medications. In this podcast I discuss documented sentinel events involving the confusion of these two… The post Heparin – Insulin Confusion: Deadly results of medication errors in the ICU and Hospital setting appeared first on NURSING.com.
MD Anderson Cancer Center is the first hospital in the United States to implement a new technology that will greatly improve chemotherapy quality control. Our main goal is patient safety. Kelley Reece, assistant manager in Pharmacy, explains how this software helps standardize the delivery of care across technicians and clinics. She also gives a behind the scenes look at how chemotherapy drugs are individually prepared for each unique patient.
Medication Safety and Medication Therapy Management. The Impact of New Regulations on Care, Conditions for Coverage, Prospective Payment System, Medicare Modernization Act, Eligibility Criteria for Medication Therapy Management, Affect of CMS Regulations on ESRD Medication Management, New Medication Concerns, Medication Delivery to ESRD Patients: Operational and Medication Safety Issues, Medication Errors, Impact on Patients, Pharmacies, and Medical Directors, Medication Reconciliation, and Medication Related Problems.
I am joined by Bryan Hayes for Part II of our discussion on the avoidance of critical medication errors during resuscitations.
I am joined by Bryan Hayes to discuss the avoidance of critical medication errors during resuscitations.
Medication Errors
Finding the right healthcare team can be a challenge for patients and caregivers. Ken Farbstein, patient safety advocate, founder of Patient Advocare and author of Getting Your Best Health care: Real-World Stories for Patient Empowerment, will be discussing the best ways to find a care team. Through caregiver stories and experience, Ken will be providing ways to partner with doctors and nurses, staying safe during a medical crisis and the general mindset for being an empowered patient. Ken is passionate about patient safety and started http://www.patientsafetyblog.com , a blog for patient safety stories. He has worked with hospitals in the Boston area to improve patient safety and decrease medication errors. He has worked to educate local state representatives on patient safety issues resulting in the enactment of essential laws governing patient safety. Be sure to listen in. This show is guaranteed to be informative, uplifting and insightful!
Medication Errors
Guest: Gary Conkright Host: Bruce Japsen Trying to reduce medication errors? Gary Conkright, chief executive officer of InformMed, a medication safety company, talks with host Bruce Japsen about how the healthcare industry is borrowing a risk assessment technique from the aviation industry as a way to improve patient safety.
Most of the time medications are beneficial, or at least they cause no harm, but on occasion they do injure the person taking them. This report brief highlights the findings and recommendation from the Institute of Medicine report, Preventing Medication Errors, to the Centers for Medicare and Medicaid Services. Read the report online. Visit the IOM report page.
Yizhak Kupfer, MD, discusses his lecture, to be held during the 36th Critical Care Congress, "Reduction of Medication Errors in the Intensive Care Unit." Dr. Kupfer is an associate professor of medicine at SUNY Downstate School of Medicine and is the director of the medical intensive care unit at Maimonides Medical Center in New York, New York.