Newspaper/Magazine Article Fatal gas line mix-up: How to avoid making this "gastly" mistake. Citation Text: ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: ISMP Medication Safety Alert! Acute care edition. December 16, 2004 Copy Citation Related Resources From the Same Author(s) Loud wake-up call: unlabeled containers lead to patient’s death. March 27, 2005 Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization. June 29, 2011 Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. July 13, 2016 Administering a saline flush "site unseen" can lead to a wrong route error. May 29, 2013 ISMP survey shows provider text messaging often runs afoul of patient safety. November 29, 2017 Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020 Pharmaceutical industry and medical device companies: part of the solution? November 29, 2006 Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020 Adverse glycemic events and critical emergencies. December 15, 2021 Accidental IV infusion of heparinized irrigation in the OR. December 21, 2016 Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. January 14, 2015 Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2. April 8, 2015 Eric Cropp weighs in on the error that sent him to prison. December 16, 2009 Prevent administration of ear drops into the eyes. December 14, 2022 Safe practice environment chapter proposed by USP. December 17, 2008 Fatal misadministration of IV vincristine. December 14, 2005 Implement strategies to prevent persistent medication errors and hazards. April 5, 2023 Controlled substance drug diversion by healthcare workers as a threat to patient safety. March 14, 2023 Pump up the volume: how to prioritize events and analyze error data. February 22, 2023 IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. September 11, 2019 FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization. September 23, 2020 Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. May 12, 2021 A recurring call to action: every healthcare organization needs a medication safety officer! March 10, 2021 Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. March 3, 2021 Start the year off right by preventing these top 10 medication errors and hazards from 2020. February 10, 2021 Learning from errors with the new COVID-19 vaccines. January 27, 2021 Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 Administration of concentrated potassium chloride for injection during a code: still deadly! June 30, 2021 More can be done to alleviate errors associated with pharmaceutical product labeling and packaging. May 19, 2021 Prevent errors during emergency use of hypertonic sodium chloride solutions. November 17, 2021 Challenges with requiring five characters during ADC drug searches via override. November 3, 2021 Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines. October 20, 2021 Disrespectful behavior in healthcare: has it improved? Please take our survey! October 21, 2021 Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020 ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. November 18, 2020 Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). October 21, 2020 During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. September 30, 2020 Start the year off right by addressing these top 10 medication safety concerns from 2021. February 9, 2022 Pump up the volume: tips for increasing error reporting and decreasing patient harm. September 8, 2021 Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021 Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. April 20, 2022 Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. March 15, 2022 Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. February 23, 2022 Safety considerations for challenges when using smart infusion pumps. November 2, 2022 Survey results from pharmacists provide support to enhance the organizational response to codes. October 26, 2022 Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. August 9, 2023 A hard look at hard stops and workarounds in the acute care setting. July 12, 2023 Assessing medication safety in settings not designated solely for pediatric patients. June 28, 2023 Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime. September 7, 2022 Medication orders with future start dates: how far away is too far? July 27, 2022 Temporarily holding medication orders safely in order to prevent patient harm. November 1, 2023 Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 Taking a closer look at medication errors that involve oxytocin. June 14, 2023 Ensuring competency and safety when onboarding newly hired professional staff. May 3, 2023 Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups. June 15, 2022 Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers. June 1, 2022 Survey shows room for improvement with three new best practices for hospitals. May 18, 2022 The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. July 1, 2020 Education is “predictably disappointing” and should never be relied upon alone to improve safety. June 24, 2020 Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? June 3, 2020 Speaking up about patient safety requires an observant questioner and a high index of suspicion. October 30, 2019 Maximize benefits of IV workflow management systems by addressing workarounds and errors. September 20, 2017 Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. October 17, 2018 IV push medications survey results—part 1 and part 2. November 28, 2018 Unverified patient-reported error: a false alarm can have real consequences. December 3, 2014 Strengthen your resolve: no unlabeled containers anywhere, ever! November 19, 2014 A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. November 5, 2014 FDA Advise-ERR: avoid using the error-prone abbreviation, TPA. October 14, 2015 Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1. September 23, 2015 Results of survey on pediatric medication safety—part 1 and part 2. June 17, 2015 South Carolina medication error bill is dangerously off target. April 29, 2015 Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. February 25, 2015 Technology and error-prevention strategies: why are we still overlooking the IV room? January 28, 2015 Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. February 24, 2016 Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. November 18, 2015 Do not let "Depo-" medications be a depot for mistakes. April 13, 2016 Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors. March 9, 2016 The "Dirty Dozen": 12 persistent safety gaffes that we need to resolve! October 22, 2014 With oral chemotherapy, we simply must do better! July 30, 2014 Accidental overdoses involving fluorouracil infusions. July 1, 2015 The absence of a drug–disease interaction alert leads to a child's death. June 3, 2015 Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. July 16, 2014 Some IV medications are diluted unnecessarily in patient care areas, creating undue risk. July 2, 2014 Misidentification of alphanumeric symbols. June 18, 2014 Administering just the diluent or one of two vaccine components leaves patients unprotected. June 4, 2014 Disrespectful behaviors—part 1 and part 2. May 7, 2014 Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. April 16, 2014 Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. February 27, 2019 Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. January 23, 2019 Are national efforts to reduce drug name confusion paying off? December 12, 2018 Partnering with families and patient advocates: another line of defense in adverse event surveillance. August 14, 2019 Independent double checks: worth the effort if used judiciously and properly. June 19, 2019 What's in a name? Newborn naming conventions and wrong-patient errors. May 8, 2019 ISMP updates its list of drug name pairs with Tall man letters. December 1, 2010 Drug shortages: national survey reveals high level of frustration, low level of safety. October 6, 2010 CMS 30-minute rule for drug administration needs revision. September 22, 2010 Survey shows recession has weakened patient safety net. January 27, 2010 Building patient safety skills: common pitfalls when conducting a root cause analysis. May 5, 2010 Latest heparin fatality speaks loudly—what have you done to stop the bleeding? April 21, 2010 Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. November 18, 2009 View More Related Resources Patient safety of perioperative medication through the lens of digital health and artificial intelligence. June 28, 2023 Evaluation of detected medication errors within the operating room at an academic medical center. June 21, 2023 Smart infusion pump investigations after an unexplained over-infusion. May 31, 2023 Interview In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023 Perspective Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023 Home medical device safety tops ECRI'S list of healthcare technology. February 15, 2023 Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long? November 9, 2022 Rethinking use of air-safety principles to reduce fatal hospital errors. September 7, 2022 FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. February 24, 2022 - February 24, 2022 The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue. November 11, 2020 Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets. November 13, 2019 Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting. September 18, 2019 Patient safety incidents caused by poor quality surgical instruments. September 4, 2019 FDA to end program that hid millions of reports on faulty medical devices. May 29, 2019 Pro/con debate: color-coded medication labels. February 20, 2019 Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. February 13, 2019 Artificial intelligence, bias and clinical safety. January 23, 2019 Insulin pumps have most reported problems in FDA database. December 5, 2018 Reducing treatment errors through point-of-care glucometer configuration. October 31, 2018 Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. October 10, 2018 The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. July 18, 2018 Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety. July 11, 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm. June 20, 2018 Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. July 13, 2016 The forgotten tourniquet—an update. March 13, 2016 Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence. August 5, 2015 The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety. January 14, 2015 The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future. October 15, 2014 National pediatric anesthesia safety quality improvement program in the United States. October 1, 2014 Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States. September 24, 2014 View More See More About The Topic Clinical Technologists Physicians Nurses Engineers Anesthesiology View More
Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization. June 29, 2011
Start the new year off right by preventing these top 10 medication errors and hazards. January 29, 2020
Hidden medication loss when using a primary administration set for small-volume intermittent infusions. December 16, 2020
Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals. January 14, 2015
Controlled substance drug diversion by healthcare workers as a threat to patient safety. March 14, 2023
IV Push Gap Analysis Tool (GAT) helps uncover national priorities for safe injection practices. September 11, 2019
FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization. September 23, 2020
Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. May 12, 2021
A recurring call to action: every healthcare organization needs a medication safety officer! March 10, 2021
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. March 3, 2021
Start the year off right by preventing these top 10 medication errors and hazards from 2020. February 10, 2021
Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021
Administration of concentrated potassium chloride for injection during a code: still deadly! June 30, 2021
More can be done to alleviate errors associated with pharmaceutical product labeling and packaging. May 19, 2021
Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns. December 2, 2020
ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy. November 18, 2020
Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). October 21, 2020
During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes. September 30, 2020
Start the year off right by addressing these top 10 medication safety concerns from 2021. February 9, 2022
Pump up the volume: tips for increasing error reporting and decreasing patient harm. September 8, 2021
Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021
Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. April 20, 2022
Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II. March 15, 2022
Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. February 23, 2022
Survey results from pharmacists provide support to enhance the organizational response to codes. October 26, 2022
Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II. August 9, 2023
Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime. September 7, 2022
Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023
Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers. June 1, 2022
The differences between human error, at-risk behavior, and reckless behavior are key to a just culture. July 1, 2020
Education is “predictably disappointing” and should never be relied upon alone to improve safety. June 24, 2020
Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts? June 3, 2020
Speaking up about patient safety requires an observant questioner and a high index of suspicion. October 30, 2019
Maximize benefits of IV workflow management systems by addressing workarounds and errors. September 20, 2017
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm. October 17, 2018
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. November 5, 2014
Managing hospitalized patients with ambulatory pumps: findings from an ISMP survey—Part 1. September 23, 2015
Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices. February 25, 2015
Technology and error-prevention strategies: why are we still overlooking the IV room? January 28, 2015
Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. February 24, 2016
Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. November 18, 2015
Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors. March 9, 2016
Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications. July 16, 2014
Some IV medications are diluted unnecessarily in patient care areas, creating undue risk. July 2, 2014
Administering just the diluent or one of two vaccine components leaves patients unprotected. June 4, 2014
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. February 27, 2019
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event. January 23, 2019
Partnering with families and patient advocates: another line of defense in adverse event surveillance. August 14, 2019
Drug shortages: national survey reveals high level of frustration, low level of safety. October 6, 2010
Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. November 18, 2009
Patient safety of perioperative medication through the lens of digital health and artificial intelligence. June 28, 2023
Evaluation of detected medication errors within the operating room at an academic medical center. June 21, 2023
Interview In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023
Perspective Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023
Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long? November 9, 2022
FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing. February 24, 2022 - February 24, 2022
The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue. November 11, 2020
Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets. November 13, 2019
Untangling infusion confusion: a comparative evaluation of interventions in a simulated intensive care setting. September 18, 2019
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. February 13, 2019
Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. October 10, 2018
The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. July 18, 2018
Intravenous smart pumps: usability issues, intravenous medication administration error, and patient safety. July 11, 2018
Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm. June 20, 2018
Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence. August 5, 2015
The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety. January 14, 2015
The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future. October 15, 2014
National pediatric anesthesia safety quality improvement program in the United States. October 1, 2014
Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States. September 24, 2014