Learning from errors with the new COVID-19 vaccines.

Newspaper/Magazine Article

Learning from errors with the new COVID-19 vaccines.

January 27, 2021

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education.

Free full text

Related Resources From the Same Author(s)

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

October 21, 2021

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

September 8, 2021

Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs.

August 11, 2021

Survey shows recession has weakened patient safety net.

January 27, 2010

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

February 24, 2016

ISMP National Vaccine Errors Reporting Program 2017 analysis—part 1 and part 2.

July 18, 2018

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

February 10, 2021

Medical abbreviations that have contradictory or ambiguous meanings.

February 12, 2020

A recurring call to action: every healthcare organization needs a medication safety officer!

March 10, 2021

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

March 3, 2021

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

July 14, 2021

More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.

May 19, 2021

Prevent errors during emergency use of hypertonic sodium chloride solutions.

November 17, 2021

Challenges with requiring five characters during ADC drug searches via override.

November 3, 2021

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

October 20, 2021

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

March 24, 2021

Medication orders with future start dates: how far away is too far?

July 27, 2022

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

February 1, 2023

Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II.

March 15, 2022

IV push medications survey results—part 1 and part 2.

November 28, 2018

Start the year off right by addressing these top 10 medication safety concerns from 2021.

February 9, 2022

Technology and error-prevention strategies: why are we still overlooking the IV room?

January 28, 2015

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

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

January 26, 2011

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

July 27, 2011

Correct use of inhalers: help patients breathe easier.

July 27, 2016

Understanding and managing IV container overfill.

December 4, 2013

Drug shortages continue to compromise patient care.

January 24, 2018

Start the new year off right by preventing these top 10 medication errors and hazards.

January 29, 2020

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

February 8, 2023

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

August 27, 2008

Anticoagulant safety takes center stage in 2007.

January 24, 2007

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

August 9, 2023

ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.

November 18, 2020

Survey shows room for improvement with three new best practices for hospitals.

May 18, 2022

Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps.

November 18, 2015

Misidentification of alphanumeric symbols.

June 18, 2014

Smart pumps in practice: survey results reveal widespread use, but optimization is challenging.

April 18, 2018

Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS.

April 1, 2020

Controlled substance drug diversion by healthcare workers as a threat to patient safety.

March 14, 2023

Results of survey on pediatric medication safety—part 1 and part 2.

June 17, 2015

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

May 12, 2021

Administration of concentrated potassium chloride for injection during a code: still deadly!

June 30, 2021

Safety considerations for challenges when using smart infusion pumps.

November 2, 2022

Survey results from pharmacists provide support to enhance the organizational response to codes.

October 26, 2022

Assessing medication safety in settings not designated solely for pediatric patients.

June 28, 2023

Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.

June 1, 2022

A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.

November 5, 2014

Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1.

September 23, 2015

Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.

February 25, 2015

Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.

March 9, 2016

The "Dirty Dozen": 12 persistent safety gaffes that we need to resolve!

October 22, 2014

Accidental overdoses involving fluorouracil infusions.

July 1, 2015

Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.

July 2, 2014

Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.

April 16, 2014

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

November 18, 2009

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

May 18, 2011

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

May 18, 2016

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

March 26, 2014

First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).

December 11, 2013

Your high-alert medication list—relatively useless without associated risk-reduction strategies.

April 17, 2013

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

September 25, 2013

Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.

April 12, 2017

Using information from external errors to signal a "clear and present danger."

March 8, 2017

Is an indication-based prescribing system in our future?

November 30, 2016

The texting debate: beneficial means of communication or safety and security risk?

July 12, 2017

Safety with nebulized medications requires an interdisciplinary team approach.

March 7, 2018

ISMP survey shows provider text messaging often runs afoul of patient safety.

November 29, 2017

Benefits and risks of including patients on RCA teams.

June 18, 2008

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

The five rights: a destination without a map.

February 7, 2007

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

July 27, 2005

Double key bounce and double keying errors.

January 31, 2006

Keeping patients safe from iatrogenic methadone overdoses.

February 27, 2008

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

February 6, 2008

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

October 14, 2015

Harmful errors: how will your facility respond?

October 18, 2006

Taking a closer look at medication errors that involve oxytocin.

June 14, 2023

Ensuring competency and safety when onboarding newly hired professional staff.

May 3, 2023

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2.

April 8, 2015

Disrespectful behaviors—part 1 and part 2.

May 7, 2014

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

July 14, 2010

Just Culture and its critical link to patient safety—part 1 and part 2.

July 25, 2012

Prevent administration of ear drops into the eyes.

December 14, 2022

Implement strategies to prevent persistent medication errors and hazards.

April 5, 2023

Pump up the volume: how to prioritize events and analyze error data.

February 22, 2023

Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns.

December 2, 2020

Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB).

October 21, 2020

Adverse glycemic events and critical emergencies.

December 15, 2021

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

April 20, 2022

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

February 23, 2022

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

July 12, 2023

Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime.

September 7, 2022

Temporarily holding medication orders safely in order to prevent patient harm.

November 1, 2023

Patient death tied to lack of proper escalation process for barcode scanning failures.

October 4, 2023

Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.

June 15, 2022

Education is “predictably disappointing” and should never be relied upon alone to improve safety.

June 24, 2020

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

September 20, 2017

Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.

October 17, 2018

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Certified Professional in Patient Safety Review Course.

June 5, 2024 - June 6, 2024

Interview

In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety

November 27, 2023

Perspectives on Safety

The Role of Undergraduate Nursing Education in Patient Safety

November 27, 2023

The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services.

May 3, 2023

WebM&M Cases

Medication Handling and Compounding Errors in the Operating Room.

March 15, 2023

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety.

March 15, 2023

An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference.

March 1, 2023

‘They can’t ignore us any more’: five women on long Covid and medical misogyny.

October 26, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

March 30, 2022

A widow’s mission to change NC dental sedation rules.

March 23, 2022

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

February 24, 2022

Start the year off right by addressing these top 10 medication safety concerns from 2021.

February 9, 2022

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

January 11, 2022

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

October 20, 2021

TRIAD IX: can a patient testimonial safely help ensure prehospital appropriate critical versus end-of-life care?

September 15, 2021

How medical jargon can make COVID health disparities even worse.

June 9, 2021

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

May 12, 2021

COVID-19 dominates annual list of patient safety concerns.

March 24, 2021

Patient Safety Primers

Medication Administration Errors

March 12, 2021

What COVID-19 teaches us about implicit bias in pediatric health care.

February 24, 2021

Drug shortages amid the COVID-19 pandemic.

February 24, 2021

The impact of critical incidents on nurses and midwives: a systematic review.

February 10, 2021

A poison information centre can provide important assessment and guidance regarding medication errors in nursing homes: a prospective cohort study.

February 3, 2021

COVID-19 Content. ISMP Medication Safety Alert!

January 14, 2021

Covid-19 surge could lead to another drop in patient visits, doctors fear—and more missed pediatric cancers.

December 23, 2020

Think health care workers are tested often for the Coronavirus? Think again.

December 16, 2020

Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns.

December 2, 2020

The optimal use of telehealth to deliver safe patient care.

October 21, 2020

See More About The Topic

Hospitals

Ambulatory Clinic or Office

Allied Health Professionals

Nurses

Pharmacists