Fluorouracil error ends tragically, but application of lessons learned will save lives.

Newspaper/Magazine Article

Fluorouracil error ends tragically, but application of lessons learned will save lives.

October 3, 2007

ISMP Medication Safety Alert! Acute care edition. September 20, 2007.

This article summarizes an incident involving chemotherapeutic agent overdose, describes factors contributing to the error, and provides recommendations for safer chemotherapy administration.

Free full text

Related Resources From the Same Author(s)

Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections.

October 3, 2012

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

September 20, 2006

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

September 23, 2020

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

September 20, 2017

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

Prescription drug time guarantees and their impact on patient safety in community pharmacies.

September 19, 2012

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

October 5, 2011

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

September 21, 2011

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

October 14, 2015

How has the current economy affected patient safety?

September 23, 2009

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

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

September 24, 2008

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

October 4, 2006

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

September 19, 2007

Paralyzed by mistakes: preventing errors with neuromuscular blocking agents.

October 5, 2005

Disrespectful behavior in healthcare: has it improved? Please take our survey!

October 21, 2021

Drug shortages: national survey reveals high level of frustration, low level of safety.

October 6, 2010

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

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

October 31, 2007

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

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

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

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

December 3, 2014

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

October 20, 2021

Actively caring for safety: overcoming bystander apathy.

December 10, 2008

Safety considerations for challenges when using smart infusion pumps.

November 2, 2022

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

October 21, 2020

Survey results from pharmacists provide support to enhance the organizational response to codes.

October 26, 2022

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

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

November 14, 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

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

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

September 30, 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

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

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

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

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

July 13, 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

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

November 29, 2017

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

Strengthen your resolve: no unlabeled containers anywhere, ever!

November 19, 2014

Related Resources

Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis.

August 2, 2023

ISMP updates its list of drug names with tall man (mixed case) letters based on survey results.

February 8, 2023

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

November 17, 2021

Use of therapeutic outcomes monitoring method for performing of pharmaceutical care in oncology patients.

April 28, 2021

The randomized AMBORA trial: impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment with new oral anticancer agents.

April 21, 2021

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

February 24, 2021

FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only.

February 3, 2021

Impact of an electronic health record transition on chemotherapy error reporting.

June 17, 2020

Systemic causes of in-hospital intravenous medication errors: a systematic review.

March 4, 2020

Pharmaceutical interventions to improve safety of chemotherapy-treated cancer patients: a cross-sectional study.

February 27, 2019

Intravenous chemotherapy compounding errors in a follow-up pan-Canadian observational study.

May 9, 2018

Oncology nurses' beliefs and attitudes towards the double-check of chemotherapy medications: a cross-sectional survey study.

March 21, 2018

Instituting vincristine minibag administration: an innovative strategy using simulation to enhance chemotherapy safety.

December 6, 2017

Eliminating vincristine administration events.

November 29, 2017

Severe drug interactions and potentially inappropriate medication usage in elderly cancer patients.

November 9, 2016

The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy.

November 9, 2016

Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management.

October 26, 2016

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.

February 3, 2016

Oral chemotherapy: not just an ordinary pill.

September 9, 2015

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

January 28, 2015

SIMMEON-Prep study: SIMulation of Medication Errors in ONcology: prevention of antineoplastic preparation errors.

December 17, 2014

Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.

December 3, 2014

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use.

September 10, 2014

With oral chemotherapy, we simply must do better!

July 30, 2014

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

July 2, 2014

How studying human factors improves patient safety.

April 16, 2014

Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study.

April 9, 2014

Medication reconciliation: getting started with IT.

March 5, 2014

Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists.

February 26, 2014

Understanding and managing IV container overfill.

December 4, 2013

See More About The Topic

Hospitals

Pharmacists

Quality and Safety Professionals

Medical Oncology

Hospital Pharmacy

Fluorouracil error ends tragically, but application of lessons learned will save lives.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Fluorouracil error ends tragically, but application of lessons learned will save lives.

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