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

Newspaper/Magazine Article

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

May 2, 2012

ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3.

This article reports results from a survey of hospital pharmacy staff on patient injury associated with drug shortages.

Free full text

Related Resources From the Same Author(s)

Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.

March 21, 2012

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

August 8, 2012

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

July 25, 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

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

July 18, 2012

Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.

July 2, 2014

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

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

November 8, 2017

FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels.

July 2, 2008

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

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

October 3, 2012

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

April 4, 2012

Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1.

September 23, 2015

Temporarily holding medication orders safely in order to prevent patient harm.

November 1, 2023

With oral chemotherapy, we simply must do better!

July 30, 2014

Building a case for medication reconciliation.

May 3, 2006

IV potassium given epidurally: getting to the "route" of the problem.

April 19, 2006

Reporting and second-order problem solving can turn short-term fixes into long-term remedies.

June 1, 2016

Small effort, big payoff...automated maximum dose alerts with hard stops.

October 2, 2013

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

May 30, 2007

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

February 6, 2008

Disrespectful behaviors—part 1 and part 2.

May 7, 2014

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

April 21, 2010

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

May 5, 2010

Another tragic parenteral nutrition compounding error.

May 11, 2011

South Carolina medication error bill is dangerously off target.

April 29, 2015

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

April 17, 2013

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

April 18, 2018

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.

May 6, 2009

Shared MDIs: can cross-contamination be avoided?

April 22, 2009

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

May 12, 2021

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

September 19, 2012

Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns.

December 2, 2020

Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.

June 1, 2022

Is an indication-based prescribing system in our future?

November 30, 2016

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Heparin errors continue despite prior, high-profile, fatal events.

August 6, 2008

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

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

March 12, 2014

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

July 16, 2014

Misidentification of alphanumeric symbols.

June 18, 2014

Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals.

January 14, 2015

Preventing errors when preparing and administering medications via enteral feeding tubes.

December 7, 2022

During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes.

September 30, 2020

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

September 8, 2021

Mail service and community pharmacies must work in tandem.

November 30, 2005

November 14, 2007

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

May 8, 2019

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

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

Fatal misadministration of IV vincristine.

December 14, 2005

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

August 15, 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

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

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

A mislabeling event with batched drugs: the unintended consequences of practice changes.

February 19, 2014

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

April 8, 2015

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

April 20, 2022

Some red rules shouldn't rule in hospitals.

May 14, 2008

FDA Advise-ERR: medication errors associated with Cerebyx.

April 23, 2008

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

December 16, 2009

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

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

July 14, 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

Related Resources

WebM&M Cases

Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable

September 27, 2023

Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’

August 23, 2023

Implement strategies to prevent persistent medication errors and hazards.

April 5, 2023

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.

March 29, 2023

Journal Article

Study

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

March 29, 2023

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

February 15, 2023

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019.

April 27, 2022

Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation.

July 21, 2021

Drug shortages amid the COVID-19 pandemic.

February 24, 2021

Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims.

November 4, 2020

Global drug shortages due to COVID-19: impact on patient care and mitigation strategies.

July 8, 2020

Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States.

June 23, 2020

Spikes in demand from coronavirus patients are creating shortages of asthma drugs and sedatives for ventilator patients.

April 22, 2020

ASHP guidelines on preventing medication errors in hospitals.

October 17, 2018

Malnutrition in the hospital: the pharmacist’s role in prevention and treatment.

September 26, 2018

The Safety of Intravenous Drug Delivery Systems: Update on Current Issues Since the 2009 Consensus Development Conference.

September 5, 2018

Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages.

June 13, 2018

Injectable Opioid Shortages: Suggestions for Management and Conservation.

April 25, 2018

The other opioid crisis: hospital shortages lead to patient pain, medical errors.

March 28, 2018

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings.

January 24, 2018

ISMP Survey on Drug Shortages.

September 13, 2017

Errors originating in hospital and health-system outpatient pharmacies.

July 19, 2017

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

June 28, 2017

Medication safety in neonatal care: a review of medication errors among neonates.

July 20, 2016

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

February 3, 2016

Evaluation of parenteral nutrition errors in an era of drug shortages.

December 16, 2015

Seven (potentially) deadly prescribing errors.

November 11, 2015

Reducing errors through discharge medication reconciliation by pharmacy services.

August 26, 2015

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

January 28, 2015

See More About The Topic

Hospitals

Pharmacists

Health Care Executives and Administrators

Hospital Pharmacy

Medication Errors/Preventable Adverse Drug Events