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

Newspaper/Magazine Article

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

July 2, 2008

ISMP Medication Safety Alert! Acute Care Edition. June 19, 2008;13:1-3.

This article addresses a drug–device interaction in which patients receiving a certain peritoneal dialysis solution may have falsely elevated blood glucose levels when measured with point-of-care blood glucose monitors.

Free full text

Related Resources From the Same Author(s)

Benefits and risks of including patients on RCA teams.

June 18, 2008

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

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

September 24, 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

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

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

July 2, 2014

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

A shortage of everything except errors: harm associated with drug shortages.

May 2, 2012

Unreadable barcodes and multiple barcodes on packages can lead to errors.

November 8, 2017

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

March 26, 2008

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

September 23, 2015

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

November 1, 2023

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

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

July 12, 2023

Misidentification of alphanumeric symbols.

June 18, 2014

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

July 26, 2006

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

June 1, 2016

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

October 2, 2013

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

July 17, 2013

Rapid response team activation by patients can mitigate errors.

June 21, 2006

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

Independent double checks: undervalued and misused.

June 26, 2013

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

December 2, 2020

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

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

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

July 13, 2016

Accidental overdoses involving fluorouracil infusions.

July 1, 2015

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

July 12, 2017

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

Independent double checks: worth the effort if used judiciously and properly.

June 19, 2019

Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!

July 18, 2007

Two steps forward and one step back for patient safety?

August 17, 2005

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

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

March 26, 2014

Strengthen your resolve: no unlabeled containers anywhere, ever!

November 19, 2014

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

November 5, 2014

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

October 22, 2014

ISMP Canada identifies themes associated with fatal medication events in the home.

March 12, 2014

With oral chemotherapy, we simply must do better!

July 30, 2014

Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications.

July 16, 2014

Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals.

January 14, 2015

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

June 28, 2023

The differences between human error, at-risk behavior, and reckless behavior are key to a just culture.

July 1, 2020

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

August 9, 2023

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

July 18, 2018

November 14, 2007

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

June 17, 2015

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

July 14, 2021

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

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

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

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

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

February 19, 2014

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

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

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

Related Resources

Assessing the clinical, economic, and health resource utilization impacts of prefilled syringes versus conventional medication administration methods: results from a systematic literature review.

December 13, 2023

WebM&M Cases

When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!

November 30, 2023

WebM&M Cases

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

August 30, 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

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Journal Article

Study

Reducing hospital harm: establishing a command centre to foster situational awareness.

March 29, 2023

WebM&M Cases

Hospital-Acquired Diabetic Ketoacidosis.

February 1, 2023

Reducing potential errors associated with insulin administration: an integrative review.

December 14, 2022

Potentially inappropriate prescribing for adults living with diabetes mellitus: a scoping review.

October 5, 2022

Administering High-Strength Insulin from a Pen Device in Hospital.

September 14, 2022

Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices.

August 24, 2022

WebM&M Cases

Challenges of Diabetes Management and Medication Reconciliation

August 5, 2022

Weight-based Medication Errors in Children.

February 16, 2022

Adverse glycemic events and critical emergencies.

December 15, 2021

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

October 13, 2021

WebM&M Cases

A Sweet Case of Hidden Hydrogen Ions

April 28, 2021

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017.

March 24, 2021

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education.

November 4, 2020

FDA advises health care professionals and patients about insulin pen packaging and dispensing.

October 28, 2020

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center.

January 29, 2020

Improving the quality of insulin prescribing for people with diabetes being discharged from hospital

October 16, 2019

WebM&M Cases

Duplicate Insulin Order

March 1, 2019

Evaluation of harm associated with high dose-range clinical decision support overrides in the intensive care unit.

January 23, 2019

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

January 23, 2019

Insulin pumps have most reported problems in FDA database.

December 5, 2018

Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors.

November 21, 2018

Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors.

August 8, 2018

Randomized controlled evaluation of an insulin pen storage policy.

February 14, 2018

See More About The Topic

Health Care Providers

Endocrinology

Nephrology

Insulin

Monitoring Errors and Failures