A physician accidentally gave a nurse telephone orders
for a heparin infusion via protocol in addition to a low
molecular weight heparin (LMWH) product twice a day. Both
medications were available in a night cabinet for use
when the pharmacy was closed. The error was recognized
when the pharmacist reviewed the nighttime orders upon
arrival at the hospital the following day. Unfortunately,
the patient died from intracranial bleeding.
In our December 13, 2000, issue, we wrote "the dosage
of parenteral calcium should be standardized at each practice
site and be based on the amount of elemental calcium rather
than the mg strength of the salt." However, unlike other
parenteral electrolyte salts such as potassium and magnesium,
the primary label panel on vials of calcium gluconate
and calcium chloride, as well as commonly used references,
continue to express the dose in terms of the amount of
the salt in grams. Regardless of the method used, the
most important error reduction strategy is to select just
one standard way to dose calcium at each institution.
Three residents of a Midwestern nursing home died after
a nitrogen tank was accidentally connected to the facility's
oxygen system. The cryogenic tank involved in this incident
was noted to have an oxygen label that was partially covered
with a smaller nitrogen label.
Readers in Spain can use the Internet to obtain safe
medication practice information. Our Spanish affiliate,
headed by Dra. Maria Jose Otero of the University of Salamanca
in Salamanca, Spain, posts safety alerts and accompanying
photographs at www3.usal.es/ismp/marco.html.
Also, Canadian pharmacists should visit www.ismp-canada.org.
ISMP Canada is headed by Canadian pharmacist David U.
Looking for ISMP-recommended error prevention strategies
to incorporate into your quality improvement efforts?
All issues of the ISMP Medication Safety Alert! from the
past five years (January 1996 to December 2000) are now
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