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ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.
This article describes instances of tissue injury as a result of the misadministration of Promethazine and provides recommendations to minimize the risk of this occurring.
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
This newsletter article reports results of a survey indicating when and why intravenous (IV) medications are unnecessarily diluted and makes recommendations to prevent this practice, such as including instructions in the medication administration record regarding dilution and educating nurses about risks. Medications were frequently diluted, which may lead to mislabeled syringes, IV medication contamination, and dosing errors.