- Newspaper/Magazine Article
- Published June 2017
Death due to pharmacy compounding error reinforces need for safety focus.
ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.
-
Topics
Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor
Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.
Related Resources
Journal Article › Study
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
Journal Article › Study
Lobaugh LMY, Martin LD, Schleelein LE, Tyler DC, Litman RS. Anesth Analg. 2017;125:936-942.
Journal Article › Study
Degnan DD, Hertig JB, Peters MJ, Stevenson JG. J Pharm Pract. 2018;31:312-321.
Journal Article › Commentary
Aung TH, Beck AJ, Siese T, Berrisford R. BMJ Qual Improv Rep. 2016:28;5:1-4.
Legislation/Regulation › Organizational Policy/Guidelines
Safe injection, infusion, and medication vial practices in health care (2016).
Dolan SA, Arias KM, Felizardo G, et al. Washington, DC: Association for Professionals in Infection Control and Epidemiology; February 2016.
Newspaper/Magazine Article
Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
Newspaper/Magazine Article
Strengthen your resolve: no unlabeled containers anywhere, ever!
ISMP Medication Safety Alert! Acute Care Edition. November 6, 2014;19:1-4.
Journal Article › Study
Donaldson N, Aydin C, Fridman M. J Nurs Adm. 2014;44:353-361.
Special or Theme Issue
PA-PSRS Patient Saf Advis. December 2009;6(suppl 1):1-32.
Press Release/Announcement
Fellowships and Mentorships Program.
Horsham, PA. Institute for Safe Medication Practices.
Audiovisual
Kaiser learns from tragic medical errors.
Rusk K. Assignment 7. ABC7news.com. May 26, 2008.
Journal Article › Commentary
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2007;42:675-679.
Meeting/Conference › Meeting/Conference Proceedings
US Food and Drug Administration, Center for Drug Evaluation and Research. January 11, 2007.
Journal Article › Review
Patient safety in geriatrics: a call for action.
Tsilimingras D, Rosen AK, Berlowitz DR. J Gerontol A Biol Sci Med Sci. 2003;58:M813-M819.
Journal Article › Study
The incidence and severity of adverse events affecting patients after discharge from the hospital.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann Intern Med. 2003;138:161-167.
Meeting/Conference › Oregon Meeting/Conference
8th Annual Oregon Patient Safety Forum.
Oregon Patient Safety Commission. March 15, 2019; Sentinel Hotel, Portland, OR.
Book/Report
Front Line of Defense: The Role of Nurses in Preventing Sentinel Events. Third Edition.
Joint Commission and the American Nurses Association. Oakbrook, IL: Joint Commission Resources, Inc; 2018. ISBN: 9781635850611.
Journal Article › Commentary
Harveian Oration 2018: improving quality and safety in healthcare.
Dixon-Woods M. Clin Med (Lond). 2019;19:47-56.
Patient Safety Primer
Patient Safety Primer
Patient Safety Primer
Legislation/Regulation › Organizational Policy/Guidelines
Patient Safety: Global Action on Patient Safety.
Executive Board EB144/29 144th session. Geneva, Switzerland: World Health Organization; December 12, 2018.
Book/Report
Framework for Effective Board Governance of Health System Quality.
Daley Ullem E, Gandhi TK, Mate K, Whittington J, Renton M, Huebner J. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.
Journal Article › Commentary
McCraw B, Crutcher T, Polancich S, Jones P. J Healthc Qual. 2018;40:392-397.
Journal Article › Study
Association of opioid prescribing with opioid consumption after surgery in Michigan.
Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. 2019;154:e184234.