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Search results for "Medication Errors/Preventable Adverse Drug Events"
- Indwelling Tubes and Catheters
- Medication Errors/Preventable Adverse Drug Events
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Cases & Commentaries
- Web M&M
Osama Loubani, MD; January 2017
A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. August 20, 2014;(53):1-6.
The Joint Commission issues sentinel event alerts in response to significant emerging safety risks for events which carry high risk and require immediate action. This alert reports on new standards for tubing connectors to prevent injury from incorrect administration of therapeutic agents. New ISO (International Organization for Standardization) standards prevent one type of tubing (such as intravenous) to be incorrectly attached to a different delivery system (such as a feeding tube.) The Joint Commission recommends multidisciplinary review of existing tubing connectors, maintaining awareness of the possibility for incorrect connections, and preparing and adopting safety connectors as soon as they are available in late 2014. A past AHRQ WebM&M commentary describes an administration error due to incorrect tubing connection.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
Journal Article > Commentary
Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.
Simmons D, Phillips MS, Grissinger M, Becker SC. Jt Comm J Qual Patient Saf. 2008;34:293-296.
Based on reports received through numerous national organizations, this article provides public policy recommendations for preventing certain tubing misconnections.