The following are excerpts from the newsletter
December 13, 2007
- Celebrating 10 years of ISMP CHEERS awards
- Safety Briefs: Error could still happen.
A variety of system problems contributed to mix-ups involving 10 units/mL heparin and 10,000 units/mL heparin products manufactured by Baxter. Read this brief to learn which factors often contribute to mix-ups and how to assess and decrease risks associated with heparin and other high alert drugs in your organization.
- Persistence saves patient’s life.
A pharmacist prevented significant patient harm by questioning an atypical methotrexate dose and persisting until his concerns were evaluated by other members of the healthcare team, including the patient’s family. This Safety Brief details other factors that contributed to this serious near-miss.
- Avoiding mix-ups between sterile water and sodium chloride bags.
Take proactive steps to prevent the inadvertent administration of sterile water instead of sodium chloride by heeding lessons learned in organizations where these often tragic errors have occurred.