Administering a saline flush "site unseen" can lead to a wrong route error.

Provide Feedback |

Submit a Case

Newspaper/Magazine Article

Administering a saline flush "site unseen" can lead to a wrong route error.

May 29, 2013

ISMP Medication Safety Alert! Acute care edition. May 16, 2013;18:1-3.

Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.

Free full text

Related Resources

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

February 23, 2023

Preventing errors when preparing and administering medications via enteral feeding tubes.

December 7, 2022

Potentially inappropriate medication administration is associated with adverse postoperative outcomes in older surgical patients: a retrospective cohort study.

September 14, 2022

Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update.

June 22, 2022

WebM&M Cases

Intraosseous Line Extravasation in a Pediatric Trauma Patient

April 27, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Targeted Medication Safety Best Practices for Hospitals.

February 2, 2022

Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened.

November 11, 2020

WebM&M Cases

Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression

May 27, 2020

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

June 19, 2019

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.

May 8, 2019

WebM&M Cases

A Potent Medication Administered in a Not So Viable Route

January 1, 2017

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

July 13, 2016

Nursing strategies to increase medication safety in inpatient settings.

May 25, 2016

Double checking: a second look.

May 18, 2016

Alarm management: first things first: using reliable data to eliminate unnecessary alarms.

December 10, 2014

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

November 5, 2014

Managing risk during transition to new ISO tubing connector standards.

August 27, 2014

Back to basics: preventing surgical site infections.

June 4, 2014

Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome?

May 14, 2014

Recognizing and managing errors of cognitive underspecification.

March 19, 2014

Practices to prevent venous thromboembolism: a brief review.

February 19, 2014

WebM&M Cases

Multifactorial Medication Mishap

February 1, 2014

Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.

January 22, 2014

Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.

December 18, 2013

Understanding and managing IV container overfill.

December 4, 2013

Using good design to eliminate medical errors.

November 20, 2013

Audit of missed or delayed antimicrobial drugs.

November 13, 2013

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

September 25, 2013

Oral medications inadvertently given via the intravenous route.

September 18, 2013

See More About

Hospitals

Health Care Providers

Quality and Safety Professionals

Anesthesiology

General Internal Medicine

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364

Administering a saline flush "site unseen" can lead to a wrong route error.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Administering a saline flush "site unseen" can lead to a wrong route error.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users