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- Communication Improvement 5
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- Error Reporting and Analysis 16
- Human Factors Engineering 23
- Legal and Policy Approaches 9
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- Policies and Operations 2
- Quality Improvement Strategies 29
- Specialization of Care 3
- Technologic Approaches 19
- Device-related Complications 8
- Discontinuities, Gaps, and Hand-Off Problems 2
- Drug shortages 1
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 1
Medication Errors/Preventable Adverse Drug Events
- Administration Errors
- Medication Errors/Preventable Adverse Drug Events
- Nonsurgical Procedural Complications 3
- Surgical Complications 2
- Internal Medicine 18
- Pediatrics 8
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- Health Care Executives and Administrators 45
Health Care Providers
- Nurses 14
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Search results for "Administration Errors"
- Newspaper/Magazine Article
- Administration Errors
ISMP Medication Safety Alert! Acute Care Edition. August 29, 2019;24.
Mistakes in the administration of intravenous (IV) medications can result in patient harm. Analyzing data from 243 health care facilities regarding the quality of IV push practices in the field, this newsletter article reports adoption of practices such as the use of a new syringe and needle for every IV push injection and outlines 10 best practices to consider for improvement, including the routine supply of IV push medications in ready-to-administer containers and reporting to external bodies to enhance learning.
ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
ISMP Medication Safety Alert! Acute Care Edition. February 22, 2018;23:1-5.
Myriad system and clinician failures can contribute to medication errors. This newsletter article reviews factors that contribute to nebulized medication administration problems, such as unlabeled solutions, look-alike packaging, equipment misuse, and storage issues. Recommendations to reduce risks include team assessment of barcode scanning processes, communicating orders, and storing vials separately.
Magee MC, Miller K, Patzek D, Madera C, Michalek C, Shetterly M. PA-PSRS Patient Saf Advis. December 2017;14.
Near misses provide unique opportunities to identify and learn from safety hazards. Describing how one organization utilized data on near misses involving barcode medication administration over a 12-year period to reduce barcode-workflow events, this report outlines practices and strategies that contributed to success such as promoting event reporting and applying root cause analysis.
Quick Safety. October 16, 2017;(37):1-3.
What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers.
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2016;21:1-3.
ISMP Medication Safety Alert! Acute Care Edition. December 4, 2014;19:1-6. March 26, 2015;20:1-4.
This newsletter series reports on 2 years of data collected during a national effort to collect vaccine administration errors. The first article summarizes information about the types of vaccine errors reported and why they occur. The second article discusses risks during vaccine use and offers recommendations to prevent them.
Tavernise S. New York Times. January 15, 2015.
This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.
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.
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.
ISMP Medication Safety Alert! Acute Care Edition. February 21, 2013;18:1-3.
This newsletter piece recommends strategies to ensure the safe transition from using insulin pens to insulin vials in acute care.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.
This newsletter piece reviews smart infusion pump errors and makes recommendations to prevent them.