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FACT SHEET/FAQS
Oral Dosage Forms that Should Not Be Crushed.
Mitchell JF. Institute for Safe Medication Practices.
NEWSPAPER/MAGAZINE ARTICLE
Loud wake-up call: unlabeled containers lead to patient’s death.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.
COMMENTARY
New technology, new errors: how to prime an upgrade of an insulin infusion pump.
Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.
COMMENTARY
SNOMED CT: electronic health record enhances anesthesia patient safety.
Elevitch FR. AANA J. 2005;73:361-366.
NEWSPAPER/MAGAZINE ARTICLE
Clear liquids may place patients at risk.
PA-PSRS Patient Saf Advis. December 2005;2:29-31.
COMMENTARY
Preventing vincristine administration errors: does evidence support minibag infusions?
Schulmeister L. Clin J Oncol Nurs. 2006;10:271-273.
NEWSPAPER/MAGAZINE ARTICLE
Promethazine conundrum: IV can hurt more than IM injection!
ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.
STUDY
Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.
Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.
ORGANIZATIONAL POLICY/GUIDELINES
Tubing misconnections—a persistent and potentially deadly occurrence.
Sentinel Event Alert. April 3, 2006;(36):1-3.
NEWSPAPER/MAGAZINE ARTICLE
Double key bounce and double keying errors.
ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.
ORGANIZATIONAL POLICY/GUIDELINES
2008 Recommendations for Pre-Anesthesia Checkout Procedures. 
ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008. 
NEWSPAPER/MAGAZINE ARTICLE
Medication administration in anesthesia: time for a paradigm shift.
Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.
PRESS RELEASE/ANNOUNCEMENT
Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions.
VA National Center for Patient Safety. Washington, DC: VA Central Office; April 6, 2006. Patient Safety Alert AL06-012.
STUDY
Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial.
Frush K, Hohenhaus S, Luo X, Gerardi M, Wiebe RA. Pediatr Emerg Care. 2006;22:62-70.
ORGANIZATIONAL POLICY/GUIDELINES
Preventing vincristine administration errors.
The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.
COMMENTARY
Patient safety in plastic surgery.
Trussler AP, Tabbal GN. Plast Reconstr Surg. 2012;130:470e-478e.
COMMENTARY
Best-practice protocols: Preventing adverse drug events.
Weir VL. Nurs Manage. 2005;36:24-30.
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