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Quick Safety. October 16, 2017;(37):1-3.
SafeMedicineUse. August 19, 2015;6:1-2.
ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.
To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.
ISMP Medication Safety Alert! Acute Care Edition. November 14, 2013;18:1-4.
This newsletter article reports on concerns associated with chemotherapy preparations due to variations in concentration and recommends standardized preparation processes to address such risks.
Death and neurological devastation from intrathecal vinca alkaloids: prepared in syringes = 120; prepared in minibags = 0.
ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013;18:1-4.
This newsletter article discusses risks associated with vincristine administration, contributing factors, and strategies to prevent errors.
Willams B. The Record. March 10, 2012.
Exploring how drug shortages affect patients, this news piece describes one cancer patient's efforts to acquire the chemotherapeutic agent that is prolonging his life.
ISMP Medication Safety Alert! Acute Care Edition. March 8, 2012;17:1-3.
This newsletter piece discusses the pros and cons of physicians dispensing medications and its impact on patient safety.
ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.
This article discusses a case of data entry error in an electronic prescribing system, explains the contributing factors, and provides recommendations to prevent such errors.
ISMP Medication Safety Alert! Acute Care Edition. December 3, 2009;14:1-3.
This article discusses how a criminal prosecution has deeply affected an Ohio pharmacist who lost his license and is serving a prison sentence for failing to detect a medical error, which led to the death of a child.
ISMP Medication Safety Alert! Acute Care Edition. September 20, 2007;12:1-3.
This article summarizes an incident involving chemotherapeutic agent overdose, describes factors contributing to the error, and provides recommendations for safer chemotherapy administration.
Paul R. Drug Topics. September 17, 2007;151:10.
This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
Fernandez J. Drug Topics. May 7, 2007.
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken against the pharmacist involved.
Finkelstein JB. J Natl Cancer Inst. 2006;98:1763-1765.
This article discusses changes implemented at Dana-Farber Cancer Institute to improve cancer medication safety, including the adoption of electronic prescribing.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2006;11:1-2.
This article summarizes intravenous vincristine safety practices collected from more than 400 responses to a national online survey.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2005;10:1-2, 4.
This alert responds to fatal medication errors involving vincristine and reiterates the importance of adhering to error reduction strategies. The Institute for Safe Medication Practices is conducting a survey on administration of intravenous vincristine; the survey is included with this alert.
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.