ISMP Medication Safety Alert! Acute Care Edition

An exhausted workforce increases the risk of errors
Use of handwritten "do not" symbol leads to confusion with an order for warfarin.
Error in package insert dosing table for ACETADOTE (acetylcysteine) could lead to delays between loading and maintenance doses.
Strangulation by IV tubing - additional safety measures may be needed for prevention of this tragedy in infants.
Sun tanning with transdermal patches could lead to unwanted side effects or lack of effectiveness.
Expression of medication expiration dates needs standardization.

June 16, 2005

Symlin insulin adjunct presents safety issues
Changes to color-coding of ophthalmic beta-blockers could cause confusion.
Name pair confusion: a patient receives rifampin instead of rifamixin (XIFAXAN)
Clarification of Lantus order containing "U" for units leads to dose uncertainty.
Potential for name confusion between OTC cholesterol lowering liquid, QWELL, and lindane products (commonly referred to by the former brand name KWELL).

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Two steps forward and one step back for patient safety?
Two groups focus on improved outcomes, another on Rx "vending" machines
Readers provide examples of problems and solutions with glacial acetic acid.
Organ storage solution resembles an IV bag; inadvertent IV administration could be fatal.
Ultrasound gel drawn into an unlabeled syringe serves as an example of the dangers of improper preparation of topical medications.
The Association of periOperative Registered Nurses (AORN) is conducting a national campaign to urge healthcare professionals to focus on reducing the risk of medication errors in operating room settings.
Another hospital received containers of hydraulic fluid instead of detergent.
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