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Newborn and Infant Nursing Reviews
Volume 8, Issue 2
, Pages 72-82
, June 2008
What Nurses Can Do Right Now to Reduce Medication Errors in the Neonatal Intensive Care Unit
References
- Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162:1897–1903
- Iatrogenic events in admitted neonates: a prospective cohort study. Lancet. 2008;371:404–410
- Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach. Intensive Care Medicine. 2000;26:69–74
- Adverse events in the neonatal intensive care unit: Development, testing and findings of an NICU-focused trigger tool to identify harm in North American NICU's. Pediatrics. 2006;118:1332–1340
- . Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83:492–497
- . Medicines for children licensed by the European Agency for the evaluation of medicinal products. Eur J Clin Pharmacol. 2002;58:495–500
- . Potential tenfold drug overdoses on a neonatal unit. Arch Dis Child Fetal neonata Ed. 2004;89:
- Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2004;89:F480–F482
- Drug error and incidents in a neonatal intensive care unit: A quality assurance activity. Am J Dis Child. 1989;143:737–740
- . Systematic evaluation of errors occurring during the preparation of intravenous medications. CMAJ. 2008;178:42–48
- . ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2005. Am J health Syst Pharm. 2006;63:327–345
- Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics. 2004;113:1609–1618
- . Comparison of methods for detecting medication errors in 36 hospital and skilled-nursing facilities. Am J Health Syst Pharm. 2002;59:436–446
- . To err is human: Building a safer health system. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy of Press; 1999;
- . Incidence and preventability of adverse drug events in hospitalized adults. J Gen intern Med. 1993;8:289–295
- Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29–34
- Systems analysis of adverse drug events. JAMA. 1995;274:35–43
- Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277:301–306
- . Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279:1200–1205
- Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114–2120
- Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111:722–729
- . Intralipid medication errors in the neonatal intensive care unit. Jt Comm J Qual Saf. 2007;33:104–111
- . Common errors of drug administration in infants: causes and avoidance. Paediatric Drugs. 1999;1:93–107
- . Tenfold errors in administration of drug doses: a neglected iatrogenic diseases in pediatrics. Pediatrics. 1986;77:848–849
- . Infant's death reinforces need for medications dispensed in ready-to-use form. ISMP Safety Alert. Horsham, PA: Institute for Safe Medication Practice. 1998;
- . Errors by pediatric residents in calculating drug doses. Arch Dis Child. 1998;79:56–58
- Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit. Pediatrics. 2008;121:123–128
- . The prevalence and nature of errors and near errors reported by hospital staff nurses. Applied Nursing Research. 2004;17:224–230
- . Patient safety in the neonatal intensive care unit. Clin Perinatology. 2005;32:97–106
- . Reporting adverse events. N Engl J Med. 1992;347:1633–1638
- Every error a treasure: improving medication use with a nonpunitive reporting system. Jt Comm J Qual Saf. 2007;33:401–407
- . Nurse perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qual. 2004;19:209–217
- Does critical incident reporting contribute to medication error prevention?. Eur J Pediatri. 2002;161:594–599
- . Another heparin error: Learning from mistakes so we don't repeat them. Horsham, PA:Institute for Safe Medication Practices; 2007;Available at: http://www.ismp.org/Newsletters/acutecare/articles/20071129.asp[Retrieved November 29, 2006]
- . Concurrent counting and typing: lateralized interference depends on a difference between the hands in moor skill. Cortex. 2006;42:38–47
- The 100-car naturalists driving study, Phase II: Results of th 100-car field study. National Highway Traffic Safety Administration, report # DOT HS 810 593, April 2006; April 2006;
- . Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142:658–665
- . Interruptive communication pattern in the intensive care unit ward round. Int J Med Inform. 2005;74:791–796
- Understanding the complexity of registered nurse work in acute care settings. J Nurs Adm. 2003;33:630–638
- . Applying airline safety practice to medication administration. Med Surg Nursing. 2003;12:77–93
- Aspden P, Corrigan J, Wolcott J, Erickson S. (editors). Patient Safety: achieving a new standard of care. Washington, DC: National Academies Press; 2004.
- . The sterile cockpit. Aviation Safety Reporting System, 4, 1-4. Available at: http://web.archive.org/web/20070410193354/http://asrs.arc.nasa.gov/directline_issues/dl4_sterile.htm1993;[Retrieved February 1, 2008]
- . Distractions, interruptions and patient safety. AORN. 2007;86:109–112
- . Innovative approaches to reducing nurses' distractions during medication administration. Journal of Continuing Education in Nursing. 2005;36:108–116
- . Distractions contribute to medication errors. Drug Topics Health-System Edition. 2003;Available at: http://www.drugtopics.com[Retrieved December 7, 2007]
- . FDA targets medication errors by requiring bar codes on drugs. Available at: Amednews.com.ama-assn.org/amednews/2004/03/15/gv110315.htm2004;[Retrieved January 8, 2008]
- . Using process control charts to monitor dispensing and checking errors. Am J Health Syst Pharm. 2000;55:946–952
- . Prevention of medication errors in the pediatric inpatient setting. American Academy of Pediatrics. Committee on Drugs and Committee on Hospital Care. Pediatrics. 2007;102:428–430
- . Adverse medical events in the NICU: epidemiology and prevention. NeoReviews. 2008;9:e8–e23
- Smetzer J. ISMP survey pinpoints weaknesses in medication practices. American Hospital Association, Health Research & Educational Trust and the Institute for Safe Medication Practices. Available at: http://www.medpathways.info [Retrieved December 15, 2007].
- . Trends of medication errors in hospitalized children. J Clin Pharmacol. 2002;42:707–710
- . Human error. Cambridge, UK: Cambridge University Press; 1990;
- Institute for Safe Medication Practice Medication Safety Alert! The virtues of independent double checks—they really are worth your time! ISMP. Available at: http://www.ismp.org/Newsletters/acutecare/articles/20030306.asp2003;[Retrieved February 2, 2008]
- . The problem of redundancy problem: why more nuclear security forces may produce less nuclear security. Risk Analysis. 2004;24:935–936
- . Reducing at-risk behavior. Jt Comm J Qual Saf. 2005;31:294–299
- . Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–1940
- The effect of executive walk rounds on nurse safety climate attitudes. BMC Health Serv Res. 2005;5:28
- . Lessons from the Denver medication error/criminal negligence case: looking beyond blaming individuals. Hosp Pharm. 1998;33:640–657
- . Lesson from Colorado: beyond blaming individuals. Nursing. 1998;98:
- . Misread label. AHRQ web M&M. Available at: http://webmm.ahrq.gov/case.aspx?caseID=392003;[Retrieved December 15, 2007]
- Orenstein C. State cites safety drug lapses at Cedars Sinai. Los Angeles Times, Jan 10, 2008. Available at: http://www.latimes.com/news/local/la-me-cedars10jan10,0,7480226.story [Retrieved January 15, 2008].
- . State finds that a series of health care violations led to an infant's death. N Y Times. 2002;Available at: http://query.nytimes.com/gst/fullpage.html?res=9C02E1D8173BF936A15756C0A9649C8B63[Retrieved December 20, 2007]
- Institute for Safe Medication Practices. Medication Safety Alert, Prevent calculation errors-avoid preparing infusions using the Rule of 6 or Brosleow tape. Horsham, PA: Institute for Safe Medication Practices; 2005. Available at: http://www.ismp.org/Newsletters/acutecare/articles/Feb05.asp [Retrieved December 20, 2007].
PII: S1527-3369(08)00035-4
doi: 10.1053/j.nainr.2008.03.008
© 2008 Elsevier Inc. All rights reserved.
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Newborn and Infant Nursing Reviews
Volume 8, Issue 2
, Pages 72-82
, June 2008
