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Newspaper/Magazine Article

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

ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.

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July 14, 2021

ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.

High-alert medication misadministration is of great concern due to the increased opportunity for harm associated with mistakes. This case describes how tubing and alarm management errors came together to result in the death of patient sedated with fentanyl.