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) Fatal gas line mix-up: How to avoid making this "gastly" mistake. March 6, 2005 Adverse glycemic events and critical emergencies. December 15, 2021 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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February 9, 2022 Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. April 20, 2022 Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. June 15, 2022 Results of survey on pediatric medication safety—part 1 and part 2. June 17, 2015 Administering just the diluent or one of two vaccine components leaves patients unprotected. June 4, 2014 How has the current economy affected patient safety? September 23, 2009 That’s the way we do things around here! March 9, 2011 Scanner beep only means the barcode has been scanned. July 13, 2011 Preventing catheter/tubing misconnections: much needed help is on the way. August 4, 2010 DTaP–Tdap mix-ups now affecting hundreds of patients. July 14, 2010 Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children. 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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
Misidentification of alphanumeric symbols in both handwritten and computer-generated information. July 15, 2009
Start the year off right by preventing these top 10 medication errors and hazards from 2020. February 10, 2021
Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021
Start the year off right by addressing these top 10 medication safety concerns from 2021. February 9, 2022
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. April 20, 2022
Administering just the diluent or one of two vaccine components leaves patients unprotected. June 4, 2014
Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children. November 16, 2011
Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. May 6, 2009
Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020
ISMP updates its list of drug names with tall man (mixed case) letters based on survey results. February 8, 2023
Controlled substance drug diversion by healthcare workers as a threat to patient safety. March 14, 2023
IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. September 11, 2019
FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization. September 23, 2020
Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. May 12, 2021
A recurring call to action: every healthcare organization needs a medication safety officer! March 10, 2021
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. March 3, 2021
Administration of concentrated potassium chloride for injection during a code: still deadly! June 30, 2021
More can be done to alleviate errors associated with pharmaceutical product labeling and packaging. May 19, 2021
Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. November 18, 2020
Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). October 21, 2020
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
Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021
Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. March 15, 2022
Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. February 23, 2022
Survey results from pharmacists provide support to enhance the organizational response to codes. October 26, 2022
Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. August 9, 2023
Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime. September 7, 2022
Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023
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
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
Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? June 3, 2020
Speaking up about patient safety requires an observant questioner and a high index of suspicion. October 30, 2019
Maximize benefits of IV workflow management systems by addressing workarounds and errors. September 20, 2017
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. October 17, 2018
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. November 5, 2014
Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1. September 23, 2015
Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. February 25, 2015
Technology and error-prevention strategies: why are we still overlooking the IV room? January 28, 2015
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. February 24, 2016
Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. November 18, 2015
Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors. March 9, 2016
Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. July 16, 2014
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