Articles in this special issue examine parenteral nutrition administration and provide tactics to improve the reliability of parenteral nutrition ordering, formulation, and delivery.

This monthly selection of error reports discusses incidents involving look-alike drug names, concentration dosage error, and harm related to abbreviation use.

… … A. … J. … L. … S. … S. … D. … DW … WW … LH … PB … C. … MR … J. … ME … D. … B. … P. … A. … S. … Quaid … Thao … Denham … … Classen … Bates … George … Burgess … Angood … Keohane … Cohen … Dingman … Foley … Ford … Martins … O'Regan … … Bates … WW George … LH Burgess … PB Angood … C. Keohane … MR Cohen … J. Dingman … ME Foley … D. Ford … B. Martins … P. …

This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.

This monthly selection of error reports discusses incidents involving incomplete administration of a two-part pediatric vaccine and drug name confusion.

This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.

This monthly selection of error reports discusses incidents involving insulin preparation, automated medication cabinet stocking, and medication list filing.

This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.

This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers.

This monthly selection of reports discusses an error involving the routing of a printed label in the pharmacy, describes examples of drug name confusion, and highlights an obscure drug concentration change.

This monthly selection of medication error reports includes information about the risks of cutting medication patches, describes examples of drug name confusion, and explains the importance of indicating the purpose for the medication on prescriptions.

This monthly selection reports on pump programming errors that led to overdoses of patient-controlled analgesia (PCA), miscommunication regarding dose and indication for alteplase, and a warning to not use empty prelabeled syringes.

This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.

This monthly selection of reports includes errors involving epidural medication administered intravenously and mistaken reuse of discontinued drugs.

The Eisenberg Award honors individuals and organizations who have made vital accomplishments in improving patient safety and quality. The 2008 honorees are Michael R. Cohen, RPh, MS, ScD; Dennis O'Leary, MD; The RAND Corporation and University of California at Los Angeles School of Medicine; National Coordinating Council for Medication Error Reporting; Anthem Blue Cross and Blue Shield of Virginia; and New York City Health and Hospitals Corporation. The awards were presented at the National Quality Forum's annual meeting on October 16, 2008 in Arlington, VA.

This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child. 

This monthly selection of medication error reports addresses examples of unclear dose preparation instructions, potential insulin storage mix ups, and drug name confusion.

This monthly selection of medication error reports includes examples of errors due to drug labels and dosage as well as danger with look-alike, color-coded eye medications.

This monthly selection of medication error reports includes examples of look-alike/sound-alike medications and a discussion of immunosuppressant dosing errors.

This monthly selection of error reports describes factors contributing to iatrogenic methadone overdoses and adverse events associated with injectable colchicine.