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

Newspaper/Magazine Article

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

March 27, 2005

ISMP Medication Safety Alert! Acute care edition. December 2, 2004.

Free full text

Related Resources From the Same Author(s)

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

March 6, 2005

Adverse glycemic events and critical emergencies.

December 15, 2021

Please don't sleep through this wake-up call.

March 27, 2005

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

July 15, 2009

Fatal misadministration of IV vincristine.

December 14, 2005

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

December 16, 2009

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

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

December 16, 2020

Results of survey on pediatric medication safety—part 1 and part 2.

June 17, 2015

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

April 8, 2015

Promethazine conundrum: IV can hurt more than IM injection!

November 15, 2006

November 14, 2007

Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.

June 15, 2022

Disrespectful behavior in healthcare...have we made any progress in the last decade?

July 17, 2013

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

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

IV vincristine survey shows safety improvements needed.

March 8, 2006

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

November 29, 2006

Harmful errors: how will your facility respond?

October 18, 2006

Double key bounce and double keying errors.

January 31, 2006

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

August 15, 2007

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

If safety is your yardstick, measuring culture from the top down must be a priority.

April 4, 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

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

Potassium may no longer be stocked on patient care units, but serious threats still exist!

October 17, 2007

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

Reducing patient harm from opiates.

March 7, 2007

The five rights: a destination without a map.

February 7, 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

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

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

November 4, 2009

Preventing medication errors during codes.

February 23, 2011

Guidelines for timely medication administration: response to the CMS "30-minute rule."

January 26, 2011

ISMP updates its list of drug name pairs with Tall man letters.

December 1, 2010

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

October 6, 2010

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

September 8, 2010

Drug shortages threaten patient safety.

August 11, 2010

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

April 21, 2010

DTaP–Tdap mix-ups now affecting hundreds of patients.

July 14, 2010

Building patient safety skills: common pitfalls when conducting a root cause analysis.

May 5, 2010

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

August 31, 2011

Oral solid medication appearance should play a greater role in medication error prevention.

August 10, 2011

Too many abandon the "second victims" of medical errors.

July 27, 2011

Scanner beep only means the barcode has been scanned.

July 13, 2011

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

June 29, 2011

Multiple latent failures align to allow a serious drug interaction to harm a patient.

May 18, 2011

Another tragic parenteral nutrition compounding error.

May 11, 2011

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

March 23, 2011

How has the current economy affected patient safety?

September 23, 2009

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

September 20, 2017

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

June 20, 2018

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

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

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

July 13, 2016

Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.

March 9, 2016

The absence of a drug–disease interaction alert leads to a child's death.

June 3, 2015

South Carolina medication error bill is dangerously off target.

April 29, 2015

Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps.

November 18, 2015

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

October 14, 2015

Accidental overdoses involving fluorouracil infusions.

July 1, 2015

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

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

September 25, 2013

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

April 17, 2013

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

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

February 22, 2012

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

October 31, 2012

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

June 19, 2013

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

May 29, 2013

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

October 3, 2012

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

August 8, 2012

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

May 2, 2012

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

April 4, 2012

Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children.

November 16, 2011

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

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

April 18, 2018

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

WebM&M Cases

Is that solution for IV or irrigation?: Fluid administration errors in the operating room.

March 25, 2020

Oral chemotherapy: a home safety educational framework for healthcare providers, patients, and caregivers.

February 19, 2020

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

May 8, 2019

What's in a name? Newborn naming conventions and wrong-patient errors.

May 8, 2019

New mother number 14.

March 20, 2019

WebM&M Cases

One Bronchoscopy, Two Errors

January 1, 2019

Enhancing pediatric perioperative patient safety.

November 29, 2017

Statement on the prevention of retained foreign bodies after surgery.

October 1, 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

Safety of the Manchester Triage System to detect critically ill children at the emergency department.

August 17, 2016

Sleep and circadian misalignment for the hospitalist: a review.

August 3, 2016

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

July 13, 2016

Alarm management: promoting safety and establishing guidelines.

May 25, 2016

Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward.

May 18, 2016

Back to basics: counting soft surgical goods.

April 20, 2016

The forgotten tourniquet—an update.

March 13, 2016

A 'paperless' wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement.

January 27, 2016

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

January 28, 2015

Alarm management: first things first: using reliable data to eliminate unnecessary alarms.

December 10, 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

Implementation of an emergency department sign-out checklist improves transfer of information at shift change.

September 3, 2014

Rethinking hospital restraints.

September 3, 2014

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.

August 20, 2014

Physician: 'I almost killed a patient' because of an advance directive.

May 14, 2014

The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study.

April 2, 2014

Do safety checklists improve teamwork and communication in the operating room? A systematic review.

January 29, 2014

Improvement of medication event interventions through use of an electronic database.

December 18, 2013

Surgical checklists: a systematic review of impacts and implementation.

September 25, 2013

See More About The Topic

Physicians

Nurses

Health Care Executives and Administrators

Latent Errors

Practice Guidelines