Errors with injectable medications: unlabeled syringes are surprisingly common!

Newspaper/Magazine Article

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

ISMP Medication Safety Alert! Acute care edition. November 15, 2007.

This article details several factors that contribute to medication errors and offers recommendations that promote effective labeling of syringes.

Free full text

Related Resources From the Same Author(s)

Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.

November 28, 2012

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

June 28, 2017

Technology and error-prevention strategies: why are we still overlooking the IV room?

January 28, 2015

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

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

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

June 28, 2023

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

December 1, 2010

IV push medications survey results—part 1 and part 2.

November 28, 2018

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

August 4, 2010

November 14, 2007

A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!

December 4, 2019

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

November 29, 2006

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Is an indication-based prescribing system in our future?

November 30, 2016

Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps.

November 18, 2015

Are national efforts to reduce drug name confusion paying off?

December 12, 2018

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

November 16, 2011

ISMP survey shows provider text messaging often runs afoul of patient safety.

November 29, 2017

Strengthen your resolve: no unlabeled containers anywhere, ever!

November 19, 2014

First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).

December 11, 2013

Actively caring for safety: overcoming bystander apathy.

December 10, 2008

Using external errors to signal a clear and present danger.

November 26, 2008

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

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

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

July 14, 2010

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

May 5, 2010

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

September 23, 2015

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

December 7, 2022

ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.

November 18, 2020

Progress with preventing name confusion errors.

August 22, 2007

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

July 18, 2007

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

February 21, 2007

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

August 11, 2021

Mail service and community pharmacies must work in tandem.

November 30, 2005

Prevent errors during emergency use of hypertonic sodium chloride solutions.

November 17, 2021

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

July 17, 2013

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

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

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

Your attention please... designing effective warnings.

September 6, 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

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

Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?

December 19, 2012

Unverified patient-reported error: a false alarm can have real consequences.

December 3, 2014

Understanding and managing IV container overfill.

December 4, 2013

Promethazine conundrum: IV can hurt more than IM injection!

November 15, 2006

Survey shows recession has weakened patient safety net.

January 27, 2010

Eric Cropp weighs in on the error that sent him to prison.

December 16, 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

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

August 31, 2011

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

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

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

May 18, 2011

Another tragic parenteral nutrition compounding error.

May 11, 2011

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

March 23, 2011

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

July 15, 2009

How has the current economy affected patient safety?

September 23, 2009

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

September 20, 2017

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

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

Understanding human over-reliance on technology.

September 28, 2016

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

September 14, 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

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

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

June 3, 2015

South Carolina medication error bill is dangerously off target.

April 29, 2015

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

October 14, 2015

Related Resources

RaDonda Vaught says some system practices contributed to fatal mistake.

March 27, 2024

Time for prefilled syringes - everywhere.

March 13, 2024

Medication errors 2023: the year in review: January through December.

March 6, 2024

ISMP's List of High-Alert Medications in Acute Care Settings.

January 14, 2024

Pediatric ADHD medication errors reported to United States poison centers, 2000 to 2021.

September 27, 2023

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

August 23, 2023

Prescribing errors in children: why they happen and how to prevent them.

June 14, 2023

Minimize medication errors in urgent care clinics.

March 15, 2023

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

February 1, 2023

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

January 26, 2023

Prevent administration of ear drops into the eyes.

December 14, 2022

ISMP survey on tall man (mixed case) lettering to reduce drug name confusion.

November 16, 2022

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

May 11, 2022

Start the year off right by addressing these top 10 medication safety concerns from 2021.

February 9, 2022

Age-related COVID-19 vaccine mix-ups.

December 15, 2021

Families are struggling to use medicines at home — we must truly involve them in their own safety.

March 10, 2021

Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.

March 3, 2021

Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB).

October 21, 2020

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

June 24, 2020

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer?

April 17, 2019

Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.

March 6, 2019

Pro/con debate: color-coded medication labels.

February 20, 2019

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

IV push medications survey results—part 1 and part 2.

November 28, 2018

Antidepressant and antipsychotic medication errors reported to United States poison control centers.

November 28, 2018

Medication errors with pediatric liquid acetaminophen after standardization of concentration and packaging improvements.

October 17, 2018

Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.

October 10, 2018

Visual acuity, literacy, and unintentional misuse of nonprescription medications.

June 13, 2018

See More About The Topic

Health Care Providers

Pharmacy

Administration Errors

Human Factors Engineering

Errors with injectable medications: unlabeled syringes are surprisingly common!

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Errors with injectable medications: unlabeled syringes are surprisingly common!

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