Fatal Medication Error
Contents |
Times Weekly News Back News Latest Community Education Hospital Professional Regulation Research and Innovation Workforce Speak Out Safely EU referendum Events Back Events Awards Back Awards Nursing Times Awards Student Nursing Times Awards Patient Safety Congress and
Fatal Medication Errors Stories
Awards Careers Live! Leadership Series Back Leadership Series Team Leaders’ Congress Directors’ Congress Deputies’ Congress fatal medication errors statistics Industry events and courses Clinical archive Back Clinical archive Cancer Cardiology Continence Diabetes End of Life and Palliative Care Healthcare IT Infection
Medication Errors In Hospitals Stories
Control Leadership Medicine Management Nutrition Pain Management Patient Safety Public Health Respiratory Vital Signs Wound Care More ... Search the archive Back Search the archive Browse by clinical topic Browse by issue date Learning units and Passport medication error stories 2015 Back Learning units and Passport Go to NT Learning Free learning units Nursing Times Learning Champions What is Nursing Times Learning? Revalidation Learning Unit List User Guide Video Guides Help Student NT Back Student NT Home Your Blogs Your Placements Your Studies Your Career Your Virtual Placement Your Chance to Win Your Subscription Student Affairs Break time Back Break time Editor's comment Book reviews Practice Blog Readers' blogs Expert opinion Role models Practice comment Jobs medication errors in nursing Subscription options Your browser is no longer supported For the best possible experience using our website we recommend you upgrade to a newer version or another browser. Close Skip to main contentSkip to navigation Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.Learn more Agree Sign in ‘Jeremy Hunt felt nursing warranted only platitudes’ Jenni Middleton, editor Search the site Search Menu Sign in Sign in Subscribe Search the siteSearch Home About Nursing Times Author guidelines NT App Your Nursing Career Search Nursing Jobs Careers Fairs Search the archive Browse by clinical topic Browse by issue date Nursing Times Weekly News Latest Community Education Hospital Professional Regulation Research and Innovation Workforce Speak Out Safely EU referendum Today's headlines Union issues trust with new 'threatening statement' 15 October, 2016 0:17 am Care home group is first to gain five top CQC ratings 15 October, 2016 0:33 am Exclusive: Council plans radical public health nurse shake-up 14 October, 2016 11:56 am Financially stricken trust to cut pay bill by 10% in six months 14 October, 2016 12:19 pm Daily news focus Exclusive: Nurse patient safety tool has r
Food Home & Garden Family Milestones Travel Outdoors Cook Like a Chef Opinion Editorials Letters to
Medication Errors Made By Nurses
the Editor Endorsements Submission Policies Health Pulse Magazine Entertainment Events apa citation Music GO! Movies Arts Restaurants Drinks Books TV Obits Jobs MORE Nation Outdoors
Citation Machine
Events Classifieds Webcams Special Publications BendHomes.com Subscribe Digital Newsstand Slideshows Submit a photo Reader Comments https://www.nursingtimes.net/roles/nurse-managers/stafford-nurse-faces-nmc-over-fatal-drug-error/5056050.article Home Local/State Business Sports Lifestyle Entertainment Obits Jobs Events Classifieds Webcams BendHomes.com Slideshows Submit a photo Movies GO! Restaurants Education Environment Bend Deschutes County Politics OSU-Cascades Elections Marijuana Home Local / State Fatal medication error took place in pharmacy | St. Charles: Wrong med inserted into patients’ http://www.bendbulletin.com/localstate/2668425-151/fatal-medication-error-took-place-in-pharmacy?entryType=0 IV bag print Share | e-mail Facebook Tweet StumbleUpon Google Breaking news Fatal medication error took place in pharmacy St. Charles: Wrong med inserted into patients’ IV bag Published Dec 8, 2014 at 02:59PM St. Charles Health System officials said the fatal medication error that resulted in a patient’s death last week happened because the wrong medication was dispensed into the IV bag the patient was given. Sisters resident Loretta Macpherson, 65, died Wednesday after being admitted to St. Charles Bend’s emergency room two days earlier with symptoms of anxiety and medication questions following recent brain surgery. She went into cardiac arrest leading to irreversible brain damage after being given a paralyzing agent called rocuronium instead of the anti-seizure medication, fosphenytoin, her physician had ordered. Dr. Michel Boileau, St. Charles’ chief clinical officer, said the wrong medication was inserted into the IV bag i
Me Forgot Password? Login or Sign up for a Free Account My Topics of Interest My CME My Profile Sign Out Home Topics Issues https://psnet.ahrq.gov/resources/resource/17785/shaping-systems-for-better-behavioral-choices-lessons-learned-from-a-fatal-medication-error WebM&M Cases Perspectives Primers Submit Case CME / CEU Training Catalog https://www.americannursetoday.com/medication-errors-dont-let-them-happen-to-you/ Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial Team Technical Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Commentary Published March 2010 Shaping systems for better behavioral choices: lessons learned from a fatal medication medication error error. Classic Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP. Topics Resource Type Journal Article › Commentary Approach to Improving Safety Root Cause Analysis Teamwork Training Bar Coding and Radiofrequency ID Tagging Teamwork Training Never Events Safety Target Administration Errors Setting of Care Labor and Delivery fatal medication error Clinical Area Obstetrics Nursing Target Audience Health Care Providers Health Care Executives and Administrators Organizational Behaviorists Error Types Active Errors Latent Errors Origin/Sponsor United States of America More Cite Copy Citation: Smetzer J ; Baker C ; Byrne FD; et al. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf. 2010; 36 Download Citation File: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager Share Facebook Twitter Linkedin Email Print This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing anti
your subscription today and never miss an issue.Subscribe Clinical Clinical Topics Practice Settings Cardiovascular Drugs and Devices End of Life Endocrine Gastrointestinal Genitourinary Health and Wellness Immune / Lymphatic Systems Infection Prevention Infusion Therapy Musculoskeletal / Orthopedics Neurology Oncology Pain Management / Sedation Palliative Care Patient Safety / Quality Pharmacology Psychiatric / Mental Health Pulmonary Rapid Response Renal Take Note - Practice Updates Wound / Ostomy Care Acute Care Community/ Public / Population Health Critical Care / Emergency / Trauma Gerontology Informatics Long-Term Care / Rehabilitation Medical / Surgery Pediatrics Perioperative Primary Care Technology / Equipment Transplantation Women's Health The power of the positiveWhat goes up must come down: Hypertension and the JNC-8 guidelines CNE Departments Practice Matters Leading the Way Inside ANA Mind/Body/Spirit Career Sphere Partnerships bring infection prevention practices to nursesDeveloping a leadership legacy Resources Insights Blog Special Reports Quizzes and Surveys Video Library Safe patient handling and mobility: The journey continuesPatient handling injuries: Risk factors and risk-reduction strategies Magnet® Search for:Advanced Search HomeJournal & Archives Current IssueArchivesSubscribeDigital EditionAuthor GuidelinesSubmit an ArticleSend a Letter to the EditorEditorial Advisory BoardAbout Clinical Topics CardiovascularDrugs and DevicesEnd of LifeEndocrineGastrointestinalGenitourinaryHealth and WellnessImmune / Lymphatic SystemsInfection PreventionInfusion TherapyMusculoskeletal / OrthopedicsNeurologyOncologyPain Management / SedationPalliative CarePatient Safety / QualityPharmacologyPsychiatric / Mental HealthPulmonaryRenalTake Note - Practice UpdatesWound / Ostomy Care Practice Settings Acute CareCommunity/ Public / Population HealthCritical Care / Emergency / TraumaGerontologyInformaticsLong-Term Care / RehabilitationMedical / SurgeryPediatricsPerioperativePrimary CareTechnology / EquipmentTransplantationWomen's Health CNEANA Insight Leading the WayPractice MattersInside ANALegal / EthicsMagnet® Resources & Tools Insights BlogSpecial ReportsQuizzes and SurveysVideo Library Mind/Body/SpiritCareer SphereAdvanced Search Legal / Ethics Back to Legal / Ethics Medication errors: Don't let them happen to you March 2010 Vol. 5 No. 3 Author: Pamela Anderson, MS, RN, APN-BC, CCRN A critical care nurse tries to catch up with her morning medications after her patient’s condition changes and he requires several procedures. He is intubated, so she decides to crush the pills and instill them into his nasogastri