Newspaper/Magazine Article Fatal gas line mix-up: How to avoid making this "gastly" mistake. Citation Text: ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Copy Citation Related Resources From the Same Author(s) Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization. June 29, 2011 Pharmaceutical industry and medical device companies: part of the solution? November 29, 2006 Loud wake-up call: unlabeled containers lead to patient’s death. March 27, 2005 Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. July 13, 2016 Administering a saline flush "site unseen" can lead to a wrong route error. May 29, 2013 ISMP survey shows provider text messaging often runs afoul of patient safety. November 29, 2017 Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020 Fatal misadministration of IV vincristine. December 14, 2005 Eric Cropp weighs in on the error that sent him to prison. December 16, 2009 Accidental IV infusion of heparinized irrigation in the OR. December 21, 2016 Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. January 14, 2015 Adverse glycemic events and critical emergencies. December 15, 2021 Safe practice environment chapter proposed by USP. December 17, 2008 Preventing medication errors during codes. February 23, 2011 Guidelines for timely medication administration: response to the CMS "30-minute rule." January 26, 2011 Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment. August 31, 2011 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 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 Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children. November 16, 2011 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 The texting debate: beneficial means of communication or safety and security risk? July 12, 2017 Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020 Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2. April 8, 2015 Product-related issues make error potential enormous with investigational drugs. November 14, 2007 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 Harmful errors: how will your facility respond? October 18, 2006 Double key bounce and double keying errors. January 31, 2006 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 Fluorouracil error ends tragically, but application of lessons learned will save lives. October 3, 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 Resolving human conflicts when questions about the safety of medical orders arise. March 26, 2008 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 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 Practitioners agree on medication reconciliation value, but frustration and difficulties abound. July 26, 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 Please don't sleep through this wake-up call. March 27, 2005 That’s the way we do things around here! March 9, 2011 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 ISMP updates its list of drug name pairs with Tall man letters. December 1, 2010 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 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 Misidentification of alphanumeric symbols in both handwritten and computer-generated information. July 15, 2009 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 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 Understanding human over-reliance on technology. September 28, 2016 "Use as directed" can cause confusion for both patients and practitioners. September 14, 2016 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 ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors. August 10, 2016 Correct use of inhalers: help patients breathe easier. July 27, 2016 Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors. March 9, 2016 The absence of a drug–disease interaction alert leads to a child's death. June 3, 2015 South Carolina medication error bill is dangerously off target. April 29, 2015 Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. November 18, 2015 FDA Advise-ERR: avoid using the error-prone abbreviation, TPA. October 14, 2015 Accidental overdoses involving fluorouracil infusions. July 1, 2015 Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. January 23, 2019 Are national efforts to reduce drug name confusion paying off? December 12, 2018 Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0. September 25, 2013 Your high-alert medication list—relatively useless without associated risk-reduction strategies. April 17, 2013 Good intention, uncertain outcome...our take on physician dispensing in offices and clinics. March 21, 2012 Smart pump custom concentrations without hard "low concentration" alerts. March 14, 2012 Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives. February 22, 2012 Sterile compounding tragedy is a symptom of a broken system on many levels. October 31, 2012 Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. June 19, 2013 Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections. October 3, 2012 Raising the index of suspicion: red flags that represent credible threats to patient safety. August 8, 2012 A shortage of everything except errors: harm associated with drug shortages. May 2, 2012 Results of our survey on drug storage, stability, compatibility, and beyond use dating. April 4, 2012 View More Related Resources Patient safety of perioperative medication through the lens of digital health and artificial intelligence. June 28, 2023 Evaluation of detected medication errors within the operating room at an academic medical center. June 21, 2023 Smart infusion pump investigations after an unexplained over-infusion. May 31, 2023 Interview In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023 Perspective Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023 Home medical device safety tops ECRI'S list of healthcare technology. February 15, 2023 Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long? November 9, 2022 Rethinking use of air-safety principles to reduce fatal hospital errors. September 7, 2022 FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. February 24, 2022 - February 24, 2022 The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue. November 11, 2020 Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets. November 13, 2019 Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting. September 18, 2019 Patient safety incidents caused by poor quality surgical instruments. September 4, 2019 FDA to end program that hid millions of reports on faulty medical devices. May 29, 2019 Pro/con debate: color-coded medication labels. February 20, 2019 Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. February 13, 2019 Artificial intelligence, bias and clinical safety. January 23, 2019 Insulin pumps have most reported problems in FDA database. December 5, 2018 Reducing treatment errors through point-of-care glucometer configuration. October 31, 2018 Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. October 10, 2018 The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. July 18, 2018 Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety. July 11, 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm. June 20, 2018 Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. July 13, 2016 The forgotten tourniquet—an update. March 13, 2016 Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence. August 5, 2015 The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety. January 14, 2015 The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future. October 15, 2014 National pediatric anesthesia safety quality improvement program in the United States. October 1, 2014 Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States. September 24, 2014 View More See More About The Topic Clinical Technologists Physicians Nurses Engineers Anesthesiology View More
Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization. June 29, 2011
Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020
Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. January 14, 2015
Guidelines for timely medication administration: response to the CMS "30-minute rule." January 26, 2011
Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment. August 31, 2011
Oral solid medication appearance should play a greater role in medication error prevention. August 10, 2011
Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. March 23, 2011
Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children. November 16, 2011
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
Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020
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
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
Fluorouracil error ends tragically, but application of lessons learned will save lives. October 3, 2007
Potassium may no longer be stocked on patient care units, but serious threats still exist! October 17, 2007
Practitioners agree on medication reconciliation value, but frustration and difficulties abound. July 26, 2006
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
Drug shortages: national survey reveals high level of frustration, low level of safety. October 6, 2010
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. September 8, 2010
Misidentification of alphanumeric symbols in both handwritten and computer-generated information. July 15, 2009
Maximize benefits of IV workflow management systems by addressing workarounds and errors. September 20, 2017
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
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
ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors. August 10, 2016
Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors. March 9, 2016
Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. November 18, 2015
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. January 23, 2019
Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0. September 25, 2013
Your high-alert medication list—relatively useless without associated risk-reduction strategies. April 17, 2013
Good intention, uncertain outcome...our take on physician dispensing in offices and clinics. March 21, 2012
Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives. February 22, 2012
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. June 19, 2013
Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections. October 3, 2012
Raising the index of suspicion: red flags that represent credible threats to patient safety. August 8, 2012
Results of our survey on drug storage, stability, compatibility, and beyond use dating. April 4, 2012
Patient safety of perioperative medication through the lens of digital health and artificial intelligence. June 28, 2023
Evaluation of detected medication errors within the operating room at an academic medical center. June 21, 2023
Interview In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023
Perspective Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023
Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long? November 9, 2022
FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. February 24, 2022 - February 24, 2022
The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue. November 11, 2020
Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets. November 13, 2019
Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting. September 18, 2019
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. February 13, 2019
Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. October 10, 2018
The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. July 18, 2018
Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety. July 11, 2018
Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm. June 20, 2018
Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence. August 5, 2015
The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety. January 14, 2015
The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future. October 15, 2014
National pediatric anesthesia safety quality improvement program in the United States. October 1, 2014
Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States. September 24, 2014