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

Newspaper/Magazine Article

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

October 4, 2006

ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.

This second part of this series discusses the three types of behavior involved in error—human error, at-risk behavior, and reckless behavior—including causes of each and appropriate responses.

Free full text

Related Resources From the Same Author(s)

Tablet splitting: Do it only if you "half" to, and then do it safely.

May 31, 2006

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

September 20, 2006

Building a case for medication reconciliation.

May 3, 2006

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

November 3, 2021

Another tragic parenteral nutrition compounding error.

May 11, 2011

The absence of a drug–disease interaction alert leads to a child's death.

June 3, 2015

Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.

April 3, 2013

A clinical reminder about the safe use of insulin vials.

March 6, 2013

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

June 3, 2009

Understanding human over-reliance on technology.

September 28, 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

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

September 24, 2008

Promethazine conundrum: IV can hurt more than IM injection!

November 15, 2006

Pump up the volume—tips for increasing error reporting.

February 22, 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

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

October 3, 2007

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

April 19, 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

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

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Reporting and second-order problem solving can turn short-term fixes into long-term remedies.

June 1, 2016

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

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 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

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

July 13, 2016

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

March 9, 2016

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

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

October 14, 2015

Small effort, big payoff...automated maximum dose alerts with hard stops.

October 2, 2013

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

Prescription drug time guarantees and their impact on patient safety in community pharmacies.

September 19, 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

Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg.

September 19, 2007

Paralyzed by mistakes: preventing errors with neuromuscular blocking agents.

October 5, 2005

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

August 31, 2011

Drug shortages continue to compromise patient care.

January 24, 2018

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

Safety considerations for challenges when using smart infusion pumps.

November 2, 2022

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

November 1, 2023

FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization.

September 23, 2020

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

October 21, 2021

Taking a closer look at medication errors that involve oxytocin.

June 14, 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

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

June 30, 2021

A mislabeling event with batched drugs: the unintended consequences of practice changes.

February 19, 2014

November 14, 2007

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

July 17, 2013

What's in a name? Newborn naming conventions and wrong-patient errors.

May 8, 2019

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

July 14, 2021

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

October 4, 2023

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

Safety requires a state of mindfulness.

March 22, 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

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

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

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

March 24, 2021

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

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

January 26, 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

Survey shows recession has weakened patient safety net.

January 27, 2010

Preventing catheter/tubing misconnections: much needed help is on the way.

August 4, 2010

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

July 14, 2010

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

RaDonda Vaught says some system practices contributed to fatal mistake.

March 27, 2024

ISMP Medication Safety Intensive.

April 12, 2024 - April 19, 2024

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Requirements for implementing a 'just culture' within healthcare organisations: an integrative review.

June 21, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Medication safety event reporting: factors that contribute to safety events during times of organizational stress.

May 24, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 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

What's changed 1 year after RaDonda Vaught's conviction?

April 12, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Effect of patient safety education interventions on patient safety culture of health care professionals: systematic review and meta-analysis.

March 29, 2023

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame.

March 29, 2023

The influence of professional identity on how the receiver receives and responds to a speaking up message: a cross-sectional study.

March 29, 2023

Lessons learned from the RaDonda Vaught ruling.

March 1, 2023

National patient safety goal to improve health care equity.

February 8, 2023

Electronic health record legal settlements in the US since the 2009 Health Information Technology for Economic and Clinical Health Act.

December 21, 2022

Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.

October 26, 2022

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

May 6, 2022 - May 6, 2022

How will state medical boards handle cases involving disclosure and apology for medical errors?

April 27, 2022

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

April 20, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Disclosing adverse events in clinical practice: the delicate act of being open.

February 2, 2022

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

January 12, 2022

Pointing fingers: verbosity of patient safety narratives is associated with attribution of blame.

December 8, 2021

Institution of just culture physician peer review in an academic medical center.

October 13, 2021

Towards safer healthcare: qualitative insights from a process view of organisational learning from failure.

August 25, 2021

Just Culture, Medication Error Prevention, and Second Victim Support: a Better Prescription for Preparing Nursing Students for Practices.

June 2, 2021

See More About The Topic

Facility and Group Administrators

Risk Managers

Quality and Safety Professionals

Medicine

Medication Safety