Provide Feedback |

Newspaper/Magazine Article

Another tragic parenteral nutrition compounding error.

June 10, 2018

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

This article analyzes a fatal error involving parenteral nutrition and makes recommendations to prevent such incidents.

Information

Related Resources From the Same Author(s)

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

June 10, 2018

Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children.

May 7, 2018

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

June 10, 2018

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

June 10, 2018

Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization.

June 10, 2018

Oral solid medication appearance should play a greater role in medication error prevention.

June 10, 2018

Preventing medication errors during codes.

June 10, 2018

Telling true stories is an ISMP hallmark: here's why you should tell stories, too.

June 10, 2018

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

February 20, 2019

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

November 3, 2021

Related Resources

WebM&M Cases

Diuretics and Electrolyte Abnormalities

July 2, 2019

WebM&M Cases

Critical Order Set Change and Critical Limb Ischemia

January 1, 2019

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

June 5, 2018

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

May 5, 2018

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

December 18, 2014

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

June 25, 2012

Computerized order entry with limited decision support to prevent prescription errors in a PICU.

April 8, 2011

The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review.

April 14, 2010

Patient safety and quality in the pediatric intensive care unit.

April 11, 2007

See More About The Topic

Intensive Care Units

Health Care Providers

Quality and Safety Professionals

Information Professionals

Critical Care

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

Another tragic parenteral nutrition compounding error.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Another tragic parenteral nutrition compounding error.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site

Submit Your Training

Continue as a Guest

Continue Logged In

Submit Your Training

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your Toolkit

Continue as a Guest

Continue Logged In

Submit Your Toolkit

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your WebM&M Case

Continue as a Guest

Continue Logged In

Submit Your WebM&M Case

Continue as a Guest

Already have a PSNet

Account?

New Users