Don't underestimate the impact of change on risk potential.

Newspaper/Magazine Article

Don't underestimate the impact of change on risk potential.

September 24, 2008

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.

Free full text

Related Resources From the Same Author(s)

Safe practice environment chapter proposed by USP.

December 17, 2008

ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events.

November 5, 2008

Collaboration focused on priority issues promotes safety.

October 22, 2008

Misprogramming PCA concentration leads to dosing errors.

September 10, 2008

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

August 27, 2008

Use of tall man letters is gaining wide acceptance.

August 13, 2008

Epidural-IV route mix-ups: reducing the risk of deadly errors.

July 16, 2008

FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels.

July 2, 2008

Benefits and risks of including patients on RCA teams.

June 18, 2008

Considering insulin pens for routine hospital use? Consider this...

May 28, 2008

Some red rules shouldn't rule in hospitals.

May 14, 2008

Actively caring for safety: overcoming bystander apathy.

December 10, 2008

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

August 31, 2011

What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.

August 24, 2016

Drug shortages continue to compromise patient care.

January 24, 2018

Resolving human conflicts when questions about the safety of medical orders arise.

March 26, 2008

Using external errors to signal a clear and present danger.

November 26, 2008

Heparin errors continue despite prior, high-profile, fatal events.

August 6, 2008

Our long journey towards a safety-minded just culture. Part I: Where we've been.

September 20, 2006

Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.

February 24, 2016

Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.

March 3, 2021

Anticoagulant safety takes center stage in 2007.

January 24, 2007

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

July 26, 2006

Fluorouracil error ends tragically, but application of lessons learned will save lives.

October 3, 2007

USA Today news series: clarifying the issues and embracing community pharmacy safety.

March 12, 2008

Keeping patients safe from iatrogenic methadone overdoses.

February 27, 2008

ADC survey shows some improvements, but unnecessary risks still exist.

February 6, 2008

Guidelines for timely medication administration: response to the CMS "30-minute rule."

January 26, 2011

FDA Advise-ERR: medication errors associated with Cerebyx.

April 23, 2008

There's more to the 60 Minutes story on heparin errors.

April 9, 2008

Drug shortages: national survey reveals high level of frustration, low level of safety.

October 6, 2010

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

How has the current economy affected patient safety?

September 23, 2009

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

September 20, 2017

Understanding human over-reliance on technology.

September 28, 2016

FDA Advise-ERR: avoid using the error-prone abbreviation, TPA.

October 14, 2015

Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0.

September 25, 2013

Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections.

October 3, 2012

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

October 5, 2011

Telling true stories is an ISMP hallmark: here's why you should tell stories, too.

September 21, 2011

Our long journey towards a safety-minded just culture. Part II: where we're going.

October 4, 2006

A hard look at hard stops and workarounds in the acute care setting.

July 12, 2023

Disrespectful behavior in healthcare: has it improved? Please take our survey!

October 21, 2021

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

August 9, 2023

Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges.

March 24, 2021

November 14, 2007

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

July 14, 2021

Disrespectful behavior in healthcare...have we made any progress in the last decade?

July 17, 2013

A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!

December 4, 2019

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

Building a case for medication reconciliation.

May 3, 2006

IV potassium given epidurally: getting to the "route" of the problem.

April 19, 2006

Safety requires a state of mindfulness.

March 22, 2006

IV vincristine survey shows safety improvements needed.

March 8, 2006

Pharmaceutical industry and medical device companies: part of the solution?

November 29, 2006

Harmful errors: how will your facility respond?

October 18, 2006

Double key bounce and double keying errors.

January 31, 2006

Fatal misadministration of IV vincristine.

December 14, 2005

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

August 15, 2007

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

If safety is your yardstick, measuring culture from the top down must be a priority.

April 4, 2007

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

Error-prone conditions that lead to student nurse-related errors.

October 31, 2007

Potassium may no longer be stocked on patient care units, but serious threats still exist!

October 17, 2007

Reducing patient harm from opiates.

March 7, 2007

The five rights: a destination without a map.

February 7, 2007

Your attention please... designing effective warnings.

September 6, 2006

Rapid response team activation by patients can mitigate errors.

June 21, 2006

High-reliability organizations (HROs): what they know that we don't (Part I).

July 27, 2005

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

Loud wake-up call: unlabeled containers lead to patient’s death.

March 27, 2005

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

March 6, 2005

Please don't sleep through this wake-up call.

March 27, 2005

Independent double checks: undervalued and misused.

June 26, 2013

Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors.

March 26, 2014

Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada.

March 11, 2020

Eric Cropp weighs in on the error that sent him to prison.

December 16, 2009

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

November 4, 2009

Preventing medication errors during codes.

February 23, 2011

ISMP updates its list of drug name pairs with Tall man letters.

December 1, 2010

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

September 8, 2010

Drug shortages threaten patient safety.

August 11, 2010

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

April 21, 2010

DTaP–Tdap mix-ups now affecting hundreds of patients.

July 14, 2010

Building patient safety skills: common pitfalls when conducting a root cause analysis.

May 5, 2010

Oral solid medication appearance should play a greater role in medication error prevention.

August 10, 2011

Too many abandon the "second victims" of medical errors.

July 27, 2011

Scanner beep only means the barcode has been scanned.

July 13, 2011

Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization.

June 29, 2011

Multiple latent failures align to allow a serious drug interaction to harm a patient.

May 18, 2011

Another tragic parenteral nutrition compounding error.

May 11, 2011

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

March 23, 2011

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

July 15, 2009

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

May 18, 2016

Do not let "Depo-" medications be a depot for mistakes.

April 13, 2016

Is an indication-based prescribing system in our future?

November 30, 2016

Related Resources

WebM&M Cases

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose

October 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

ISMP updates its list of drug names with tall man (mixed case) letters based on survey results.

February 8, 2023

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

February 1, 2023

At US hospitals, a drug mix-up is just a few keystrokes away.

May 11, 2022

ASHP guidelines on the safe use of automated dispensing devices.

August 29, 2021

Dispensing Errors.

December 16, 2020

Failure mode and effects analysis to reduce risk of heparin use.

January 29, 2020

Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—a survey of users.

August 8, 2018

Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages.

June 13, 2018

Safe implementation of standard concentration infusions in paediatric intensive care.

August 24, 2016

Risk factors for i.v. compounding errors when using an automated workflow management system.

July 27, 2016

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

February 3, 2016

Maximizing smart pump technology to enhance patient safety.

July 29, 2015

Computerized dose range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit.

November 19, 2014

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis.

May 21, 2014

Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections.

June 5, 2013

Patient safety in the context of neonatal intensive care: research and educational opportunities.

October 26, 2011

Another tragic parenteral nutrition compounding error.

May 11, 2011

Utilising improvement science methods to optimise medication reconciliation.

April 13, 2011

The impact of type of manual medication cart filling method on the frequency of medication administration errors: a prospective before and after study.

February 23, 2011

Guidelines for timely medication administration: response to the CMS "30-minute rule."

January 26, 2011

Automated drug dispensing system reduces medication errors in an intensive care setting.

September 29, 2010

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

Impact of computerized orders for pediatric continuous drug infusions on detecting infusion pump programming errors: a simulated study.

June 16, 2010

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

May 12, 2010

Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies.

May 5, 2010

ISMP medication error report analysis.

April 21, 2010

ISMP medication error report analysis.

March 10, 2010

Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process.

February 17, 2010

See More About The Topic

Children's Hospitals

Nurses

Pharmacists

Quality and Safety Professionals

Critical Care

Don't underestimate the impact of change on risk potential.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Don't underestimate the impact of change on risk potential.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site