title: Best-practice protocols: preventing adverse drug events.
abstract: Analysis of Stanford's electronic Patient Safety Net revealed a pattern of unrecognized, widespread, low-frequency I.V.-PCA adverse events. A performance improvement-failure modes and effects analysis identified causes, and a multidisciplinary team developed solutions.
authors.affiliation: Stanford Hospital and Clinics, Stanford, CA, USA.
authors.forename: Vickey L
authors.initials: VL
authors.lastname: Weir
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems / Q000458:organization & administration*; D016058:Analgesia, Patient-Controlled / Q000009:adverse effects* / Q000451:nursing / Q000592:standards; D019985:Benchmarking / Q000458:organization & administration*; D002140:California; D015984:Causality; D002985:Clinical Protocols / Q000592:standards; D016903:Drug Monitoring; D004868:Equipment Failure; D006804:Ergonomics; D006801:Humans; D008508:Medication Errors / Q000379:methods / Q000451:nursing / Q000517:prevention & control* / Q000706:statistics & numerical data; D010149:Postoperative Pain / Q000188:drug therapy; D010348:Patient Care Team / Q000458:organization & administration; D012308:Risk Management / Q000458:organization & administration; D013597:Systems Analysis; D017749:Total Quality Management / Q000458:organization & administration*