Newspaper/Magazine Article Loud wake-up call: unlabeled containers lead to patient’s death. Citation Text: ISMP Medication Safety Alert! Acute care edition. December 2, 2004. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 27, 2005 ISMP Medication Safety Alert! Acute care edition. December 2, 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 2, 2004. Copy Citation Related Resources From the Same Author(s) Adverse glycemic events and critical emergencies. December 15, 2021 Fatal gas line mix-up: How to avoid making this "gastly" mistake. March 6, 2005 Fatal misadministration of IV vincristine. December 14, 2005 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. 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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 Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 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 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 Maximize benefits of IV workflow management systems by addressing workarounds and errors. September 20, 2017 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 Unverified patient-reported error: a false alarm can have real consequences. December 3, 2014 Strengthen your resolve: no unlabeled containers anywhere, ever! November 19, 2014 A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. November 5, 2014 The "Dirty Dozen": 12 persistent safety gaffes that we need to resolve! October 22, 2014 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 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. 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September 25, 2013 View More See More About The Topic Physicians Nurses Health Care Executives and Administrators Latent Errors Practice Guidelines View More
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
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
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
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
Potassium may no longer be stocked on patient care units, but serious threats still exist! October 17, 2007
Fluorouracil error ends tragically, but application of lessons learned will save lives. October 3, 2007
Failure to cap IV tubing and disinfect IV ports place patients at risk for infections. August 15, 2007
Practitioners agree on medication reconciliation value, but frustration and difficulties abound. July 26, 2006
ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent. May 30, 2007
Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023
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
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
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
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
Maximize benefits of IV workflow management systems by addressing workarounds and errors. September 20, 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
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
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
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. November 5, 2014
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
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
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 Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023
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
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
Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward. May 18, 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
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
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