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

Newspaper/Magazine Article

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

July 14, 2010

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

This piece reports on examples of confusion between adult and pediatric immunizations and states that the similar abbreviations are a main cause of the problem.

Free full text

Related Resources From the Same Author(s)

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

August 4, 2010

Drug shortages threaten patient safety.

August 11, 2010

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

July 15, 2009

Heparin errors continue despite prior, high-profile, fatal events.

August 6, 2008

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

ISMP updates its list of drug name pairs with Tall man letters.

December 1, 2010

Building patient safety skills: common pitfalls when conducting a root cause analysis.

May 5, 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

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

August 15, 2007

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

July 26, 2006

Safety requires a state of mindfulness.

March 22, 2006

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

July 27, 2005

Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices.

August 12, 2020

Students have a key role in a culture of safety: analysis of student-associated medication incidents.

August 8, 2018

Survey results: smart pump data analytics pump metrics that should be monitored to improve safety.

July 25, 2018

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

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

August 10, 2011

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

July 27, 2011

Raising the index of suspicion: red flags that represent credible threats to patient safety.

August 8, 2012

With oral chemotherapy, we simply must do better!

July 30, 2014

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

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

August 24, 2005

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

July 16, 2014

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

August 11, 2021

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

July 27, 2022

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

July 14, 2021

Scanner beep only means the barcode has been scanned.

July 13, 2011

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

November 16, 2011

Administering just the diluent or one of two vaccine components leaves patients unprotected.

June 4, 2014

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.

May 6, 2009

Fatal outcome after inadvertent injection of topical epinephrine.

April 8, 2009

How has the current economy affected patient safety?

September 23, 2009

That’s the way we do things around here!

March 9, 2011

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

Using external errors to signal a clear and present danger.

November 26, 2008

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

October 4, 2006

Heed this warning! Don't miss important computer alerts.

February 21, 2007

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

May 31, 2006

Action needed to prevent dangerous heparin-insulin confusion.

May 16, 2007

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

August 9, 2023

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

February 19, 2014

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

February 10, 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

Speaking up about patient safety requires an observant questioner and a high index of suspicion.

October 30, 2019

Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose.

May 20, 2020

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

May 8, 2019

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

February 27, 2019

Partnering with families and patient advocates: another line of defense in adverse event surveillance.

August 14, 2019

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

July 17, 2013

IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices.

September 11, 2019

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

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

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

February 6, 2008

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

November 14, 2007

Error-prone conditions that lead to student nurse-related errors.

October 31, 2007

Please don't sleep through this wake-up call.

March 27, 2005

IV vincristine survey shows safety improvements needed.

March 8, 2006

Double key bounce and double keying errors.

January 31, 2006

Fatal misadministration of IV vincristine.

December 14, 2005

Pharmaceutical industry and medical device companies: part of the solution?

November 29, 2006

Harmful errors: how will your facility respond?

October 18, 2006

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

September 20, 2006

Reducing patient harm from opiates.

March 7, 2007

The five rights: a destination without a map.

February 7, 2007

Potassium may no longer be stocked on patient care units, but serious threats still exist!

October 17, 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

Your attention please... designing effective warnings.

September 6, 2006

Rapid response team activation by patients can mitigate errors.

June 21, 2006

Building a case for medication reconciliation.

May 3, 2006

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

April 19, 2006

Two steps forward and one step back for patient safety?

August 17, 2005

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

If safety is your yardstick, measuring culture from the top down must be a priority.

April 4, 2007

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

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

July 25, 2012

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

June 17, 2015

During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes.

September 30, 2020

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

September 23, 2020

Hidden medication loss when using a primary administration set for small-volume intermittent infusions.

December 16, 2020

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

July 1, 2020

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

June 24, 2020

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

January 23, 2019

Are national efforts to reduce drug name confusion paying off?

December 12, 2018

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

October 17, 2018

Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts?

June 3, 2020

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

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

April 18, 2018

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Related Resources

Patient Safety Innovations

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

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture.

August 31, 2022

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

June 15, 2022

At US hospitals, a drug mix-up is just a few keystrokes away.

May 11, 2022

TeamSTEPPS for the COVID-19 Crisis.

February 10, 2021

Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science.

November 25, 2020

Pandemic presents new hurdles, and hope, for people struggling with addiction.

June 10, 2020

Pro/con debate: color-coded medication labels.

February 20, 2019

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

May 31, 2017

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

March 9, 2016

WebM&M Cases

Fire in the Hole!—An OR Fire

April 1, 2015

Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.

June 19, 2013

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

October 5, 2011

Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.

September 14, 2011

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

August 31, 2011

The pain of wrong site surgery.

July 6, 2011

WebM&M Cases

Patient Safety and Adherence to Self-Administered Medications

July 1, 2011

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

June 29, 2011

Applying the Universal Protocol to improve patient safety in radiology services.

June 22, 2011

Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip).

June 22, 2011

Wrong body part, wrong patient surgeries continue despite new procedures.

June 8, 2011

WebM&M Cases

Say It Again

June 1, 2011

Process changes to increase compliance with the Universal Protocol for bedside procedures.

June 1, 2011

Identifying the 'right patient': nurse and consumer perspectives on verifying patient identity during medication administration.

May 11, 2011

Another tragic parenteral nutrition compounding error.

May 11, 2011

Preventing sentinel events caused by family members.

April 13, 2011

Critical phase distractions in anaesthesia and the sterile cockpit concept.

March 30, 2011

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

March 23, 2011

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.

March 16, 2011

See More About The Topic

Health Care Providers

Risk Managers

Quality and Safety Professionals

Infectious Diseases

Active Errors