Newspaper/Magazine Article Fatal gas line mix-up: How to avoid making this "gastly" mistake. Citation Text: ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Copy Citation Related Resources From the Same Author(s) Loud wake-up call: unlabeled containers lead to patient’s death. March 27, 2005 ISMP survey shows provider text messaging often runs afoul of patient safety. November 29, 2017 Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020 Administering a saline flush "site unseen" can lead to a wrong route error. May 29, 2013 Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. July 13, 2016 Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization. June 29, 2011 Pharmaceutical industry and medical device companies: part of the solution? November 29, 2006 Adverse glycemic events and critical emergencies. December 15, 2021 Prevent administration of ear drops into the eyes. December 14, 2022 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 Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2. April 8, 2015 Safe practice environment chapter proposed by USP. December 17, 2008 Fatal misadministration of IV vincristine. December 14, 2005 Eric Cropp weighs in on the error that sent him to prison. December 16, 2009 Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. March 15, 2022 Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. February 23, 2022 Start the year off right by addressing these top 10 medication safety concerns from 2021. February 9, 2022 Medication orders with future start dates: how far away is too far? July 27, 2022 Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 Prevent errors during emergency use of hypertonic sodium chloride solutions. November 17, 2021 Safety considerations for challenges when using smart infusion pumps. November 2, 2022 Survey results from pharmacists provide support to enhance the organizational response to codes. October 26, 2022 Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime. September 7, 2022 Controlled substance drug diversion by healthcare workers as a threat to patient safety. March 14, 2023 Pump up the volume: how to prioritize events and analyze error data. February 22, 2023 Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. June 15, 2022 Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers. June 1, 2022 Survey shows room for improvement with three new best practices for hospitals. May 18, 2022 Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. April 20, 2022 IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. September 11, 2019 ISMP updates its list of drug names with tall man (mixed case) letters based on survey results. February 8, 2023 Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. February 1, 2023 Preventing errors when preparing and administering medications via enteral feeding tubes. December 7, 2022 Temporarily holding medication orders safely in order to prevent patient harm. November 1, 2023 Ensuring competency and safety when onboarding newly hired professional staff. May 3, 2023 Implement strategies to prevent persistent medication errors and hazards. April 5, 2023 Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. August 9, 2023 A hard look at hard stops and workarounds in the acute care setting. July 12, 2023 Assessing medication safety in settings not designated solely for pediatric patients. June 28, 2023 Taking a closer look at medication errors that involve oxytocin. June 14, 2023 A recurring call to action: every healthcare organization needs a medication safety officer! March 10, 2021 Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. March 3, 2021 Start the year off right by preventing these top 10 medication errors and hazards from 2020. February 10, 2021 Learning from errors with the new COVID-19 vaccines. January 27, 2021 Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020 ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. November 18, 2020 Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). October 21, 2020 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 Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 Administration of concentrated potassium chloride for injection during a code: still deadly! June 30, 2021 More can be done to alleviate errors associated with pharmaceutical product labeling and packaging. May 19, 2021 Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. May 12, 2021 Challenges with requiring five characters during ADC drug searches via override. November 3, 2021 Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines. October 20, 2021 Disrespectful behavior in healthcare: has it improved? Please take our survey! October 21, 2021 Pump up the volume: tips for increasing error reporting and decreasing patient harm. September 8, 2021 Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021 ISMP National Vaccine Errors Reporting Program 2017 analysis—part 1 and part 2. July 18, 2018 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 Maximize benefits of IV workflow management systems by addressing workarounds and errors. September 20, 2017 Death due to pharmacy compounding error reinforces need for safety focus. June 28, 2017 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 Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm. June 20, 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 Is an indication-based prescribing system in our future? November 30, 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 Safety with nebulized medications requires an interdisciplinary team approach. March 7, 2018 Drug shortages continue to compromise patient care. January 24, 2018 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 Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. March 26, 2014 ISMP Canada identifies themes associated with fatal medication events in the home. March 12, 2014 A mislabeling event with batched drugs: the unintended consequences of practice changes. February 19, 2014 First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP). December 11, 2013 Understanding and managing IV container overfill. December 4, 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 Disrespectful behavior in healthcare...have we made any progress in the last decade? July 17, 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 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 Results of our survey on drug storage, stability, compatibility, and beyond use dating. April 4, 2012 Good intention, uncertain outcome...our take on physician dispensing in offices and clinics. March 21, 2012 Smart pump custom concentrations without hard "low concentration" alerts. March 14, 2012 View More 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 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 Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology. May 7, 2014 View More See More About The Topic Clinical Technologists Physicians Nurses Engineers Anesthesiology View More
Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020
Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization. June 29, 2011
Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020
Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. January 14, 2015
Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. March 15, 2022
Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. February 23, 2022
Start the year off right by addressing these top 10 medication safety concerns from 2021. February 9, 2022
Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023
Survey results from pharmacists provide support to enhance the organizational response to codes. October 26, 2022
Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime. September 7, 2022
Controlled substance drug diversion by healthcare workers as a threat to patient safety. March 14, 2023
Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers. June 1, 2022
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. April 20, 2022
IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. September 11, 2019
ISMP updates its list of drug names with tall man (mixed case) letters based on survey results. February 8, 2023
Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. February 1, 2023
Preventing errors when preparing and administering medications via enteral feeding tubes. December 7, 2022
Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. August 9, 2023
A recurring call to action: every healthcare organization needs a medication safety officer! March 10, 2021
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. March 3, 2021
Start the year off right by preventing these top 10 medication errors and hazards from 2020. February 10, 2021
Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. November 18, 2020
Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). October 21, 2020
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
Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021
Administration of concentrated potassium chloride for injection during a code: still deadly! June 30, 2021
More can be done to alleviate errors associated with pharmaceutical product labeling and packaging. May 19, 2021
Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. May 12, 2021
Pump up the volume: tips for increasing error reporting and decreasing patient harm. September 8, 2021
Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021
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
Maximize benefits of IV workflow management systems by addressing workarounds and errors. September 20, 2017
Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. April 12, 2017
Smart pumps in practice: survey results reveal widespread use, but optimization is challenging. April 18, 2018
Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm. June 20, 2018
Despite technology, verbal orders persist, read back is not widespread, and errors continue. May 31, 2017
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
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
Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors. March 26, 2014
A mislabeling event with batched drugs: the unintended consequences of practice changes. February 19, 2014
First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP). December 11, 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
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. June 19, 2013
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
Results of our survey on drug storage, stability, compatibility, and beyond use dating. April 4, 2012
Good intention, uncertain outcome...our take on physician dispensing in offices and clinics. March 21, 2012
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
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
Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long? November 9, 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
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. February 13, 2019
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
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
Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology. May 7, 2014