Fatal gas line mix-up: How to avoid making this "gastly" mistake.

Newspaper/Magazine Article

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

March 6, 2005

ISMP Medication Safety Alert! Acute care edition. December 16, 2004

Free full text

Related Resources From the Same Author(s)

Loud wake-up call: unlabeled containers lead to patient’s death.

March 27, 2005

Fatal misadministration of IV vincristine.

December 14, 2005

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

December 16, 2020

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

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

January 14, 2015

Safe practice environment chapter proposed by USP.

December 17, 2008

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

December 16, 2009

Prevent administration of ear drops into the eyes.

December 14, 2022

Adverse glycemic events and critical emergencies.

December 15, 2021

Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2.

April 8, 2015

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

November 29, 2006

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

July 13, 2016

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

November 29, 2017

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

May 29, 2013

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

June 29, 2011

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

January 29, 2020

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

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

July 14, 2021

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

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

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

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

August 15, 2007

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

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

Two steps forward and one step back for patient safety?

August 17, 2005

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

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

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

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

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

August 12, 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

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

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

April 18, 2018

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

September 20, 2017

Is an indication-based prescribing system in our future?

November 30, 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

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

June 1, 2016

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

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

June 20, 2018

Drug shortages continue to compromise patient care.

January 24, 2018

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

November 8, 2017

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

July 12, 2017

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

May 31, 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

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

December 3, 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

Your high-alert medication list—relatively useless without associated risk-reduction strategies.

April 17, 2013

Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.

April 3, 2013

A clinical reminder about the safe use of insulin vials.

March 6, 2013

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

October 2, 2013

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

September 25, 2013

FentaNYL patch fatalities linked to "bystander apathy." We ALL have a role in prevention!

August 21, 2013

Independent double checks: undervalued and misused.

June 26, 2013

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

June 19, 2013

Results of our survey on drug storage, stability, compatibility, and beyond use dating.

April 4, 2012

Related Resources

Patient safety of perioperative medication through the lens of digital health and artificial intelligence.

June 28, 2023

Evaluation of detected medication errors within the operating room at an academic medical center.

June 21, 2023

Smart infusion pump investigations after an unexplained over-infusion.

May 31, 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

Home medical device safety tops ECRI'S list of healthcare technology.

February 15, 2023

Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long?

November 9, 2022

Rethinking use of air-safety principles to reduce fatal hospital errors.

September 7, 2022

FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.

February 24, 2022 - February 24, 2022

The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue.

November 11, 2020

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting.

September 18, 2019

Patient safety incidents caused by poor quality surgical instruments.

September 4, 2019

FDA to end program that hid millions of reports on faulty medical devices.

May 29, 2019

Pro/con debate: color-coded medication labels.

February 20, 2019

Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

February 13, 2019

Artificial intelligence, bias and clinical safety.

January 23, 2019

Insulin pumps have most reported problems in FDA database.

December 5, 2018

Reducing treatment errors through point-of-care glucometer configuration.

October 31, 2018

Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review.

October 10, 2018

The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database.

July 18, 2018

Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety.

July 11, 2018

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

June 20, 2018

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

July 13, 2016

The forgotten tourniquet—an update.

March 13, 2016

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.

August 5, 2015

The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety.

January 14, 2015

The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future.

October 15, 2014

National pediatric anesthesia safety quality improvement program in the United States.

October 1, 2014

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

September 24, 2014

See More About The Topic

Clinical Technologists

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

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