Anonymous Medication Error Reporting
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& Bioassays Resources...DNA & RNABLAST (Basic Local Alignment Search medication error reporting form Tool)BLAST (Stand-alone)E-UtilitiesGenBankGenBank: BankItGenBank: SequinGenBank: tbl2asnGenome WorkbenchInfluenza VirusNucleotide medication error reporting procedure DatabasePopSetPrimer-BLASTProSplignReference Sequence (RefSeq)RefSeqGeneSequence Read Archive (SRA)SplignTrace ArchiveUniGeneAll DNA & RNA medication error reporting format Resources...Data & SoftwareBLAST (Basic Local Alignment Search Tool)BLAST (Stand-alone)Cn3DConserved Domain Search Service (CD Search)E-UtilitiesGenBank: BankItGenBank: SequinGenBank:
Medication Error Reporting Categories
tbl2asnGenome ProtMapGenome WorkbenchPrimer-BLASTProSplignPubChem Structure SearchSNP Submission ToolSplignVector Alignment Search Tool (VAST)All Data & Software Resources...Domains & StructuresBioSystemsCn3DConserved Domain Database (CDD)Conserved Domain Search Service (CD Search)Structure (Molecular Modeling Database)Vector Alignment Search Tool (VAST)All Domains medication error reporting and prevention & Structures Resources...Genes & ExpressionBioSystemsDatabase of Genotypes and Phenotypes (dbGaP)E-UtilitiesGeneGene Expression Omnibus (GEO) Database Gene Expression Omnibus (GEO) DatasetsGene Expression Omnibus (GEO) ProfilesGenome WorkbenchHomoloGeneMap ViewerOnline Mendelian Inheritance in Man (OMIM)RefSeqGeneUniGeneAll Genes & Expression Resources...Genetics & MedicineBookshelfDatabase of Genotypes and Phenotypes (dbGaP)Genetic Testing RegistryInfluenza VirusMap ViewerOnline Mendelian Inheritance in Man (OMIM)PubMedPubMed Central (PMC)PubMed Clinical QueriesRefSeqGeneAll Genetics & Medicine Resources...Genomes & MapsDatabase of Genomic Structural Variation (dbVar)GenBank: tbl2asnGenomeGenome ProjectGenome ProtMapGenome WorkbenchInfluenza VirusMap ViewerNucleotide DatabasePopSetProSplignSequence Read Archive (SRA)SplignTrace ArchiveAll Genomes & Maps Resources...HomologyBLAST (Basic Local Alignment Search Tool)BLAST (Stand-alone)BLAST Link (BLink)Conserved Domain Database (CDD)Conserved Domain Search Service (CD Search)Genome ProtMapHomoloGeneProtein Clust
Home Food Drugs Medical Devices Radiation-Emitting Products Vaccines, Blood & Biologics Animal & Veterinary Cosmetics Tobacco Products Drugs Home Drugs Resources for You Information for Consumers (Drugs) Strategies to Reduce Medication Errors: Working to Improve Medication Safety Share medication error reporting a survey of nursing staff Tweet Linkedin Pin it More sharing options Linkedin Pin it Email Print When Jacquelyn Ley shattered
Medication Error Reporting Flow Chart
her elbow on the soccer field, her parents set out to find her the best care in Minneapolis. "We drove past five other hospitals
Medication Error Reporting Policy Procedure
to get to the one we wanted," says Carol Ley, M.D., an occupational health physician. Her husband, an orthopedic surgeon, made sure Jacquelyn got the right surgeon. After a successful three-hour surgery to repair the broken bones, Jacquelyn, who was http://www.ncbi.nlm.nih.gov/pubmed/17683099 9 at the time, received the pain medicine morphine through a pump and was hooked up to a heart monitor, breathing monitor, and blood oxygen monitor. Her recovery was going so well that doctors decided to turn off the morphine pump and to forgo regular checks of her vital signs.Carol Ley slept in her daughter's hospital room that night. When she woke up in the middle of the night and checked on her, Jacquelyn was barely breathing. "I called her name, http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm but she wouldn't respond," she says. "I shook her and called for help." The morphine pump hadn't been shut down, but had accidentally been turned up high. The narcotic flooded Jacquelyn's body. She survived the overdose, but it was a close call. "If three more hours had gone by, I don't think Jacquelyn would have survived," Ley says. "Fortunately, I woke up."Ley was pleased with the way the hospital handled the error. "They came right out and said the morphine pump was incorrectly programmed, they told me the steps they were going to take to make sure Jacquelyn was OK, and they also told me what they were going to do to make sure this kind of mistake won't happen again. And that's very important to me." The hospital began using pumps that are easier to use and revamped nurses' training. Ley believes there were many contributors to the error, including the fact that it was Labor Day weekend and there were staff shortages. "It goes to show that this can happen to anyone, anywhere," says Ley, who now chairs the board of the National Patient Safety Foundation.Multiple FactorsSince 1992, the Food and Drug Administration has received nearly 30,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no "typical" medication error, and health professionals, patients, and their families are all involved. Som
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