Reducing patient harm from opiates.

Newspaper/Magazine Article

Reducing patient harm from opiates.

March 7, 2007

ISMP Medication Safety Alert! Acute care edition. February 22, 2007.

This article lists common risks associated with opiates, a high-alert medication, as well as recommended safety improvements to reduce these risks.

Free full text

Related Resources From the Same Author(s)

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

April 4, 2007

Safety with nebulized medications requires an interdisciplinary team approach.

March 7, 2018

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

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

May 30, 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

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

The five rights: a destination without a map.

February 7, 2007

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

May 12, 2021

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

May 5, 2010

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

November 4, 2009

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

October 5, 2011

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

April 4, 2012

Heed this warning! Don't miss important computer alerts.

February 21, 2007

Using information from external errors to signal a "clear and present danger."

March 8, 2017

November 14, 2007

Administering just the diluent or one of two vaccine components leaves patients unprotected.

June 4, 2014

Paralyzed by mistakes: preventing errors with neuromuscular blocking agents.

October 5, 2005

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

Your attention please... designing effective warnings.

September 6, 2006

IV vincristine survey shows safety improvements needed.

March 8, 2006

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts?

June 3, 2020

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

February 23, 2022

A recurring call to action: every healthcare organization needs a medication safety officer!

March 10, 2021

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

ISMP Canada identifies themes associated with fatal medication events in the home.

March 12, 2014

Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.

February 25, 2015

Inattentional blindness: what captures your attention?

March 11, 2009

Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs).

March 4, 2009

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

March 9, 2016

Preventing medication errors during codes.

February 23, 2011

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

Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!

July 18, 2007

Progress with preventing name confusion errors.

August 22, 2007

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

September 20, 2017

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.

April 12, 2017

Unreadable barcodes and multiple barcodes on packages can lead to errors.

November 8, 2017

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

May 31, 2017

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

November 29, 2017

ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.

November 18, 2020

Prevent errors during emergency use of hypertonic sodium chloride solutions.

November 17, 2021

Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.

February 24, 2016

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

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

July 17, 2013

Resolving human conflicts when questions about the safety of medical orders arise.

March 26, 2008

ADC survey shows some improvements, but unnecessary risks still exist.

February 6, 2008

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

November 29, 2006

Harmful errors: how will your facility respond?

October 18, 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

Double key bounce and double keying errors.

January 31, 2006

Fatal misadministration of IV vincristine.

December 14, 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

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

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

March 27, 2005

Pump up the volume: how to prioritize events and analyze error data.

February 22, 2023

Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.

March 3, 2021

Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada.

March 11, 2020

A clinical reminder about the safe use of insulin vials.

March 6, 2013

Pump up the volume—tips for increasing error reporting.

February 22, 2006

That’s the way we do things around here!

March 9, 2011

Anticoagulant safety takes center stage in 2007.

January 24, 2007

Remote CPOE error—a situation that's more than remotely possible.

June 13, 2007

Action needed to prevent dangerous heparin-insulin confusion.

May 16, 2007

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

September 19, 2007

More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.

May 19, 2021

Start the new year off right by preventing these top 10 medication errors and hazards.

January 29, 2020

Speaking up about patient safety requires an observant questioner and a high index of suspicion.

October 30, 2019

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

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

August 14, 2019

Independent double checks: worth the effort if used judiciously and properly.

June 19, 2019

Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.

October 17, 2018

Adverse glycemic events and critical emergencies.

December 15, 2021

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

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

April 18, 2018

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

June 20, 2018

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

The texting debate: beneficial means of communication or safety and security risk?

July 12, 2017

Drug shortages continue to compromise patient care.

January 24, 2018

The "Dirty Dozen": 12 persistent safety gaffes that we need to resolve!

October 22, 2014

With oral chemotherapy, we simply must do better!

July 30, 2014

Accidental overdoses involving fluorouracil infusions.

July 1, 2015

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

June 3, 2015

Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications.

July 16, 2014

Related Resources

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.

October 4, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Ensuring competency and safety when onboarding newly hired professional staff.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Minimize medication errors in urgent care clinics.

March 15, 2023

Reducing potential errors associated with insulin administration: an integrative review.

December 14, 2022

Prevent administration of ear drops into the eyes.

December 14, 2022

ASHP Guidelines on Preventing Diversion of Controlled Substances.

December 14, 2022

Press Play on Safety Conversations.

December 7, 2022

ISMP survey on tall man (mixed case) lettering to reduce drug name confusion.

November 16, 2022

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults.

March 30, 2022

The pain was unbearable. So why did doctors turn her away?

August 25, 2021

"Talk About Your Medicines" Month.

April 4, 2021

Avoiding a Med-Wreck: a structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources.

March 3, 2021

Doctors and dentists still flooding U.S. with opioid prescriptions.

July 29, 2020

WebM&M Cases

A Mistaken Dose of Naloxone 

December 18, 2019

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.

May 22, 2019

Assessing the use of Google Translate for Spanish and Chinese translations of emergency department discharge instructions.

March 20, 2019

Are national efforts to reduce drug name confusion paying off?

December 12, 2018

Strategies for optimizing OR drug safety.

April 4, 2018

Prescription Drug Monitoring Programs: Evidence-based Practices to Optimize Prescriber Use.

February 8, 2017

Medication errors involving overrides of healthcare technology.

January 20, 2016

Over-the-counter medicines' benefits and dangers.

December 9, 2015

Fentanyl transdermal system (marketed as Duragesic) information.

July 10, 2015

Best practices: an electronic drug alert program to improve safety in an accountable care environment.

July 1, 2015

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Medicine

Nursing

Pharmacy