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Cases & Commentaries
- Web M&M
Nancy Staggers, PhD, RN; October 2017
Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.
Journal Article > Review
Bigham BL, Buick JE, Brooks SC, Morrison M, Shojania KG, Morrison LJ. Prehosp Emerg Care. 2012;16:20-35.
This systematic review found that the literature base on patient safety issues in prehospital care is still quite small, limiting emergency medical services providers' ability to identify and address systematic problems in care.