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

Newspaper/Magazine Article

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

October 3, 2012

ISMP Medication Safety Alert! Acute Care Edition. September 20, 2012;17:1,3-4.

This article describes how multiple-dose containers of intravenous radiological contrast media can spread infection and makes recommendations to address this risk.

Free full text - republished

Related Resources From the Same Author(s)

Smart pump custom concentrations without hard "low concentration" alerts.

March 14, 2012

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

October 3, 2007

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

September 19, 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

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

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

Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.

February 22, 2012

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

December 19, 2012

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

November 28, 2012

Sterile compounding tragedy is a symptom of a broken system on many levels.

October 31, 2012

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

August 8, 2012

Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.

July 18, 2012

A shortage of everything except errors: harm associated with drug shortages.

May 2, 2012

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

July 25, 2012

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

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

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

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

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

Related Resources

Quality and Safety in Health Care.

August 13, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

July 11, 2023

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

June 28, 2023

Implement strategies to prevent persistent medication errors and hazards.

April 5, 2023

Medication errors: the year in review: January through December 2021.

January 11, 2023

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

Recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic: a scoping review.

October 5, 2022

Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update.

June 22, 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

Estimation of breast cancer overdiagnosis in a U.S. breast screening cohort.

March 16, 2022

Ensuring critical instruments and devices are appropriate for reuse.

March 2, 2022

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

February 23, 2022

Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products

December 22, 2021

Prevent errors during emergency use of hypertonic sodium chloride solutions.

November 17, 2021

Infection Prevention Compendium For Long-Term Care Facilities.

September 1, 2021

Machine learning is booming in medicine. It’s also facing a credibility crisis.

June 16, 2021

In the eye of the storm: the role of the pharmacist in medication safety during the COVID-19 pandemic at an urban teaching hospital.

December 23, 2020

Recommendations of individualized medical treatment and common adverse events management for lung cancer patients during the outbreak of COVID-19 epidemic.

May 13, 2020

Joint Statement on Multiple Patients Per Ventilator.

April 22, 2020

Psychological impact and coping strategies of frontline medical staff in Hunan between January and March 2020 during the outbreak of Coronavirus Disease 2019 (COVID‑19) in Hubei, China.

April 8, 2020

Reduce the likelihood of patient harm associated with the use of anticoagulant therapy: commentary from the Anticoagulation Forum on the Updated Joint Commission NPSG.03.05.01 Elements of Performance

March 4, 2020

Artificial intelligence makes bad medicine even worse.

February 5, 2020

ASHP guidelines on perioperative pharmacy services.

August 28, 2019

ACR guidance document on MR safe practices: updates and critical information 2019.

August 14, 2019

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

August 14, 2019

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.

May 8, 2019

Patient safety in medical imaging: a joint paper of the European Society of Radiology (ESR) and the European Federation of Radiographer Societies (EFRS).

May 8, 2019

See More About The Topic

Hospitals

Health Care Providers

Radiology

Hospital Pharmacy

Nosocomial Infections