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Cases & Commentaries
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Victoria Rich, PhD, RN; August 2009
Admitted to the ICU for COPD exacerbation and atrial fibrillation, a patient who had stabilized is left unattended in the bathroom while the nurse on an understaffed unit attends to a more emergent patient. An assistant later finds the patient on the floor, unresponsive and cyanotic.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2007;12:1-2.
This article describes how errors involving potassium chloride still occur and discusses further strategies to prevent tragic mistakes with this medication.