Recente Articles - MSA Acute Care Edition

past articles from the ISMP Medication Safety Alert!

6/13/2013	Independent Double Checks: Undervalued and Misused: Selective use of this strategy can play an important role in medication safety
5/30/2013	Fatal PCA adverse events continue to happen… Better patient monitoring is essential to prevent harm
5/16/2013	Administering a saline flush “site unseen” can lead to a wrong route error
5/2/2013	Survey results show medication safety information provided by ISMP is valued and acted upon by US hospitals
4/18/2013	QuarterWatch (April 2013 issue) Perspective on GLP-1 agents for diabetes
4/4/2013	Your high-alert medication list—Relatively useless without associated risk-reduction strategies
3/21/2013	Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit
3/7/2013	Survey results: Community liaison programs to decrease hospital readmissions
2/21/2013	A clinical reminder about the safe use of insulin vials
2/7/2013	Ongoing concern about insulin pen reuse shows hospitals need to consider transitioning away from the
1/24/2013	Survey results: How hospitals are managing the preparation and purchase of high-risk compounded sterile preparations (CSPs)
1/10/2013	QuarterWatch™ (2012—Quarter 2) Signals for finasteride, methylphenidate patches, and anticoagulants
12/13/2012	The 15th Annual ISMP Cheers Awards: Meet this year’s true gems in medication safety
11/29/2012	Side tracks on the safety express. Interruptions lead to errors and unfinished… Wait, what was I doing?
11/15/2012	Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community
11/1/2012	Moving forward for safer sterile compounding
10/18/2012	Sterile compounding tragedy is a symptom of a broken system on many levels
10/4/2012	QuarterWatch™ (2012—Quarter 1) Signals for DULoxetine, pioglitazone, aliskiren, and rivaroxaban
9/20/2012	Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections
9/6/2012	Prescription drug time guarantees and their impact on patient safety in community pharmacies
8/23/2012	Avoiding inadvertent IV injection of oral liquids
8/9/2012	ISMP survey reveals user issues with Carpuject prefilled syringes
7/26/2012	Raising the index of suspicion: Red flags that represent credible threats to patient safety
7/12/2012	Just Culture and its critical link to patient safety (Part II)
6/28/2012	Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors
6/14/2012	Dr. Leape and colleagues present a compelling call to action to establish a culture of respect
5/31/2012	QuarterWatch™2011 Annual Report An estimated 2 to 4 million drug-induced serious injuries in 2011
5/17/2012	Just Culture and its critical link to patient safety (Part I)
5/3/2012	Cheers honoree’s acceptance speech creates pause for reflection
4/19/2012	A shortage of everything except errors: Harm associated with drug shortages
4/5/2012	QuarterWatch™ (second quarter 2011) Signals identified for fingolimod and inFLIXimab
3/22/2012	Results of our survey on drug storage, stability, compatibility, and beyond use dating
3/8/2012	Good intention, uncertain outcome... Our take on physician dispensing in offices and clinics
2/23/2012	Smart pump custom concentrations without hard “low concentration” alerts
2/9/2012	Results of ISMP survey on High-Alert Medications: Differences between nursing, pharmacy, and risk/quality/safety perspectives
1/26/2012	Don’t let the “tobacco stain” on pharmacies that sell cigarettes be a barrier to advanced pharmacy practice (Report to Surgeon General calls for recognition and compensation of pharmacists)
1/26/2012	Does the CMS?standard to store medications according to manufacturer’s directions impact drug shortages and increase waste?
1/12/2012	QuarterWatch™ (First Quarter 2011) Signals for dabigatran and metoclopramide
12/15/2011	14th Annual ISMP CHEERS Awards... Winners honored in New Orleans amid All that Jazz…
12/1/2011	Look out for Lugol’s... Error-prevention strategies for this strong iodine solution
11/17/2011	Conservative prescribing needed to improve medication safety
11/3/2011	Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children
10/20/2011	FDA Advise-ERR: FDA approves HYDROmorphone labeling revisions to reduce medication errors
10/6/2011	QuarterWatch™ 2010 (Quarter 4 and annual summary) Signals for two newly approved drugs: dabigatran and dalfampridine
9/22/2011	Durasal-Durezol mix-up illustrates how dangerous product problems persist long after recognition
9/8/2011	Telling true stories is an ISMP hallmark Here’s why you should tell stories, too…
8/25/2011	Gray market, black heart: Pharmaceutical gray market finds a disturbing niche during the drug shortage crisis
08/11/2011	Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment
07/28/2011	Oral solid medication appearance should play a greater role in medication error prevention
07/14/2011	Too many abandon the "second victims" of medical errors
06/30/2011	Scanner beep only means the barcode has been scanned
06/16/2011	Parents can detect, contribute to, or be affected by critical events during a child's hospitalization
06/02/2011	Safe practices in pharmacy sterile compounding areas
05/19/2011	QuarterWatchT: 2010 (Quarter 3) New signals for liraglutide, QUEtiapine, and varenicline
05/05/2011	Multiple latent failures align to allow a serious drug interaction to harm a patient
04/21/2011	Another tragic parenteral nutrition compounding error
04/07/2011	TPN-related deaths call for FDA guidance and pharmacy board oversight of USP Chapter <797>
03/24/2011	Diabetes in Control.com-A website for medical professionals
03/10/2011	Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside
02/24/2011	That's the way we do things around here! Your ACTIONS speak louder than words when it comes to patient safety
02/10/2011	Preventing medication errors during codes
01/27/2011	ISMP QuarterWatchT Report (2010 Quarter 2) Adverse drug event signals warrant action
01/13/2011	Guidelines for timely medication administration Response to the CMS "30-minute rule"
12/16/2010	The 13th Annual CHEERS Awards: And the Winners Are.
12/02/2010	Perilous infection control practices with needles, syringes, and vials suggest stepped-up monitoring is needed
11/18/2010	ISMP updates its list of drug name pairs with TALL man letters
11/04/2010	ISMP QuarterWatchT Report (2010 Quarter 1) Signals for acetaminophen, dronedarone, and botulinum toxins
10/21/2010	Dakin's solution accidentally given IV
10/07/2010	Weathering the storm: Managing the drug shortage crisis
09/23/2010	Special Issue Drug shortages: National survey reveals high level of frustration, low level of safety
09/09/2010	CMS 30-minute rule for drug administration needs revision
08/26/2010	Electronic prescribing vulnerabilities: Height and weight mix-up leads to dosing error
08/12/2010	Affirmative warnings (do this) may be better understood than negative warnings (do not do that)
08/12/2010	Generic enoxaparin syringe issue
07/29/2010	Drug shortages threaten patient safety
07/15/2010	Preventing catheter/tubing misconnections: Much needed help is on the way
07/01/2010	DTaP-Tdap mix-ups now affecting hundreds of patients
06/17/2010	ISMP QuarterWatch (Quarter 4 and 2009 totals) - Reported patient deaths increased by 14% in 2009
06/03/2010	Failure to set a volume limit for a magnesium bolus dose leads to harm
05/20/2010	Safe practice with the potent once daily opioid Exalgo
05/06/2010	Preventing errors when administering drugs via an enteral feeding tube
04/22/2010	Building Patient Safety Skills Common pitfalls when conducting a root cause analysis
04/08/2010	Latest heparin fatality speaks loudly-What have you done to stop the bleeding?
03/11/2010	ISMP develops guidelines for standard order sets
03/25/2010	California Department of Public Health Medication Error Reduction Plan
03/11/2010	ISMP develops guidelines for standard order sets
02/25/2010	ISMP QuarterWatchT (2009 Quarters 1, 2, and 3) Increased reports of ADEs with Zicam cold products, rosiglitazone, QUEtiapine, testosterone gel, and recalled products
02/11/2010	FDA Advise-ERR: A new look for Morphine Sulfate 100 mg per 5 mL (20 mg/mL) Oral Solution
01/28/2010	Baclofen programming error with SynchroMed II pump Facility not made aware of company's software updates
01/14/2010	Survey shows recession has weakened patient safety net
12/17/2009	Santa checks his list twice. Shouldn't we?
12/03/2009	Eric Cropp weighs in on the error that sent him to prison
11/19/2009	Shakespeare was on target-don't be a borrower or lender
11/05/2009	Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions
10/22/2009	Oral syringes: A crucial and economical risk-reduction strategy that has not been fully utilized
10/08/2009	ISMP QuarterWatchT Serious adverse drug event reports increase last quarter, 2008
09/24/2009	ISMP survey helps define near miss and close call
09/10/2009	How has the current economy affected patient safety?
08/27/2009	Ohio government plays Whack-a-Mole with pharmacist
08/13/2009	Plain D5W or hypotonic saline solutions post-op could result in acute hyponatremia and death in healthy children
07/30/2009	Will color-tinted IV tubing help?
07/16/2009	Process for handling elastomeric pain relief balls (ON-Q PainBuster and others) requires safety improvements
07/02/2009	Misidentification of alphanumeric symbols in both handwritten and computer-generated information
06/18/2009	Intrathecal injection warrants mask worn by clinician during procedure
06/04/2009	Icons and symbols on IV related products: Global industry must reflect on the safety aspects.
05/21/2009	Survey on LASA drug name pairs: Who knows what's on your list and the best ways to prevent mix-ups?
05/07/2009	QuarterWatch (3rd quarter 2008) Safety concerns with generics, Chantix aggressive behavior, and more
04/23/2009	Failed check system for chemotherapy leads to pharmacist's no contest plea for involuntary manslaughter
04/09/2009	Shared MDIs: Can cross-contamination be avoided?
03/26/2009	Fatal outcome after inadvertent injection of topical EPINEPHrine
03/12/2009	Beware of basal opioid infusions with PCA therapy
02/26/2009	Inattentional blindness: What captures your attention?
02/12/2009	Follow ISMP Guidelines to safeguard the design and use of automated dispensing cabinets (ADCs)
01/29/2009	Revatio=sildenafil=Viagra
01/15/2009	ISMP QuarterWatchT (2nd quarter 2008)
12/18/2008	Color-coded syringes for anesthesia drugs: use with care
12/04/2008	Safe practice environment chapter proposed by USP
11/20/2008	Actively caring for safety: Overcoming bystander apathy
11/06/2008	Using external errors to signal a clear and present danger
10/23/2008	ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events
10/09/2008	Collaboration focused on priority issues promotes safety
09/25/2008	Report and spread information about software risks
09/11/2008	Don't underestimate the impact of change on risk potential
08/28/2008	Misprogramming PCA concentration leads to dosing errors
08/14/2008	Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning
07/31/2008	Use of tall man letters is gaining wide acceptance
07/17/2008	Heparin errors continue despite prior, high-profile, fatal events
07/03/2008	Epidural-IV route mix-ups: Reducing the risk of deadly errors
06/19/2008	FDA Advise-ERR: Prevent dangerous drug-device interaction causing falsely elevated glucose levels
06/05/2008	Benefits and risks of including patients on RCA teams
05/22/2008	Managing visits from pharmaceutical sales representatives
05/08/2008	Considering insulin pens for routine hospital use? Consider this...
04/24/2008	Some red rules shouldn't rule in hospitals
04/10/2008	FDA Advise-ERR: Medication errors associated with Cerebyx
03/27/2008	There's more to the 60 Minutes story on heparin errors
03/13/2008	Resolving human conflicts when questions about the safety of medical orders arise
02/28/2008	USA Today news series: Clarifying the issues and embracing community pharmacy safety
02/14/2008	Keeping patients safe from iatrogenic methadone overdoses
01/31/2008	Fatal overdose uncovers need to rethink where pediatric IV medications are dispensed and administered
01/17/2008	ADC survey shows some improvements, but unnecessary risks still exist
12/13/2007	Celebrating 10 years of ISMP CHEERS awards
11/29/2007	Another heparin error: Learning from mistakes so we don't repeat them
11/15/2007	Errors with injectable medications: Unlabeled syringes are surprisingly common!
11/01/2007	Product-related issues make error potential enormous with investigational drugs
10/18/2007	Error-prone conditions that lead to student-nurse related errors.
10/04/2007	Potassium may no longer be stocked on patient care units, but serious threats still exist!
09/20/2007	Fluorouracil error ends tragically, but application of lessons learned will save lives
09/06/2007	Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg
08/23/2007	Lack of standard dosing methods contributes to IV errors
08/09/2007	Progress with preventing name confusion errors
07/26/2007	Failure to cap IV tubing and disinfect IV ports place patients at risk for infections
07/12/2007	Requirement #1-Patch should stick to the patient!
06/28/2007	Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!
06/14/2007	Infusion free-flow apparently still a risk
05/31/2007	Remote CPOE error-a situation that's more than remotely possible
05/17/2007	ISMP 2007 survey on HIGH-ALERT medications Differences between nursing and pharmacy perspectives still prevalent
05/03/2007	Action needed to prevent dangerous heparin-insulin confusion
04/19/2007	Smart pumps are not smart on their own
04/05/2007	Failure to clearly link TYLENOL products to acetaminophen poses serious threat to safety
03/22/2007	If safety is your yardstick, measuring culture from the top down must be a priority
03/08/2007	Criminal prosecution of human error will likely have dangerous long-term consequences
02/22/2007	HIGH ALERT Medication Feature Reducing patient harm from opiates
02/08/2007	Heed this warning! Don't miss important computer alerts
01/25/2007	The five rights: A destination without a map
01/11/2007	High-Alert Medication Feature: Anticoagulant safety takes center stage in 2007
12/14/2006	The 9th Annual ISMP CHEERS Awards: And The Winners Are...
11/30/2006	PEN injectors: Technology is not without imPENding risks
11/16/2006	Pharmaceutical industry medical device companies: Part of the solution?
11/02/2006	Promethazine conundrum: IV can hurt more than IM injection! Survey spurs interest in renewing efforts to prevent serious tissue damage
10/19/2006	"And the 'EYES' have it": Eardrops, that is...
10/05/2006	Harmful errors: How will your facility respond?
09/21/2006	Our long journey towards a safety-minded Just Culture Part II: Where we're going
09/07/2006	Our long journey towards a safety-minded Just Culture Part I: Where we’ve been
08/24/2006	Your attention please. Designing effective warnings
08/10/2006	Action needed to prevent serious tissue injury with IV promethazine
07/27/2006	ISMP comments on IOM report, Preventing Medication Errors
07/13/2006	Practitioners agree on medication reconciliation value, but frustration and difficulties abound
06/29/2006	Vincristine therapy: days "4-11" misunderstood as days 4 through 11
06/15/2006	Preventing accidental IV infusion of breast milk in neonates
06/01/2006	Rapid response team activation by patients can mitigate errors
05/18/2006	Tablet splitting: Do it only if you "half" to, and then do it safely
05/04/2006	Pump design flaws demonstrate need for practitioner involvement in FMEA
04/20/2006	Original document needed to scan orders to pharmacy
04/06/2006	IV potassium given epidurally: getting to the "route" of the problem
03/23/2006	Safety requires a state of "mindfulness" (Part II)
03/09/2006	Safety requires a state of "mindfulness" (Part I)
02/23/2006	IV vincristine survey shows safety improvements needed
02/09/2006	Pump up the volume - Tips for increasing error reporting
01/26/2006	What does your patient safety brochure really say about safety?
01/12/2006	Infusion pump double key bounce and double keying errors
12/15/2005	The 8th Annual ISMP CHEERS Awards: And the winners are...
12/01/2005	Fatal misadministration of IV vincristine
11/17/2005	Mail service and community pharmacies must work in tandem
11/03/2005	Propofol sedation: Who should administer?
10/20/2005	Preventing magnesium toxicity in obstetrics
10/06/2005	Unfortunately, this time it wasn't the equipment
09/22/2005	Paralyzed by mistakes. Preventing errors with neuromuscular blocking agents
09/08/2005	Be aware of false glucose results with point–of-care testing
08/25/2005	Safety still compromised by computer weaknesses Comparing 1999 and 2005 pharmacy computer field test results
08/11/2005	New fentanyl warnings: more needed to protect patients
07/28/2005	High-reliability organizations (HROs): What they know that we don't (Part II)
07/14/2005	High-reliability organizations (HROs): What they know that we don't (Part I)
06/30/2005	Two steps forward and one step back for patient safety? Two groups focus on improved outcomes, another on Rx "vending" machines
06/16/2005	Symlin insulin adjunct presents safety issues
06/02/2005	An exhausted workforce increases the risk of errors
05/19/2005	Practitioners anticipate punitive action from licensing bodies
05/05/2005	End the ice age-Is glacial acetic acid really needed?
04/21/2005	Building a case for medication reconciliation
04/07/2005	Patient's watchful eye and Internet lead to pump tampering
03/24/2005	Medication orders: Don't put me on hold Joint Commission and use of the Broselow tape Sterile cockpit
03/10/2005	Measuring up to medication safety
02/24/2005	Welcome to the State Board of (Nursing, Pharmacy, Medicine) Inquisitions
02/10/2005	The truth about hospital formularies Survey shows many myths still exist 15 years later

01/27/2005	New dangers in the drug reimportation process: Will we know what our patients are taking?
01/13/2005	Looking forward: Make "pro-change" your New Year's Resolution
12/16/2004	Fatal gas line mix-up: How to avoid making this "gastly" mistake 2004 ISMP CHEERS for medication safety: Celebrating excellence
12/02/2004	Loud wake-up call: Unlabeled containers lead to patient's death
11/18/2004	The truth about hospital formularies: We've come a long way, or have we?
11/04/2004	FDA and the pharmaceutical industry must be more responsive for a safer healthcare system
10/21/2004	Hazard Alert! ISMP urges immediate replacement of Brethine ampuls with vials!
10/07/2004	Reducing "at-risk behaviors" Part II of Patient safety should NOT be a priority in healthcare!
09/23/2004	Patient safety should NOT be a priority in healthcare! Part I: Why we engage in "at-risk behaviors"
09/09/2004	Inflated risk: Inadvertent drug injections into inflation port Potential confusion with AMARYL (glimepiride) and REMINYL (galantamine)
08/26/2004	Root causes: A roadmap to action
08/12/2004	Hospital and medical staff leadership is key to compliance with JC dangerous abbreviation list
07/29/2004	Misprogram a PCA pump? It's easy!
07/15/2004	Lowdown on lomustine: We’d hate CeeNU make this mistake
07/01/2004	An omnipresent risk of morphine-hydromorphone mix-ups
06/17/2004	Problems persist with life-threatening tubing misconnections
06/03/2004	Oops, sorry, wrong patient!Applying the JC “two-identifier” rule beyond the patient’s room
05/20/2004	The high cost of medications: A bitter pill to swallow
05/06/2004	Bicillin products: Syringe enhancements may help to prevent IV administration
04/22/2004	Improvised drug delivery: A cause for concern Hazard warning with BRETHINE and METHERGINE.
04/08/2004	Burns in MRI patients wearing transdermal patches Confusion caused by several different products with DULCOLAX brand name.
03/25/2004	Intimidation: Practitioners speak up about this unresolved problem (Part II)
03/11/2004	Intimidation: Practitioners speak up about this unresolved problem (Part I)
02/26/2004	Broselow tape: Measuring the changes from 1998 to today
02/12/2004	Safety issues with adding lidocaine to IV potassium infusions
01/29/2004	Evidence-based medicine doesn’t preclude common sense
01/15/2004	Template for disaster? Fatal injection into wrong port of implanted infusion pump
12/18/2003	2003 CHEERS for medication safety: Celebrating excellence ISMP's list of high-alert medications
11/27/2003	Intrathecal injection of ionic contrast media may be fatal
11/13/2003	A spectrum of problems with using color
10/30/2003	Double-checks for endogenous and exogenous errors
10/16/2003	Survey on high-alert medications Differences between nursing and pharmacy perspectives revealed
10/02/2003	Helping to remove the barriers to patient education
09/18/2003	How sterile water bags show up on nursing units
09/04/2003	Cultural diversity and medication safety
08/21/2003	Is an antithyroid or antimetabolite needed?
08/07/2003	How are you preventing acetaminophen overdoses?
07/24/2003	Part II - How to prevent errors - Safety issues with patient-controlled analgesia
07/10/2003	Safety issues with patient-controlled analgesia Part I - How errors occur
06/26/2003	New data monitoring technology offers real-time reporting of impending adverse events
06/12/2003	Blood pressure monitor tubing may connect to IV ports
05/29/2003	Mind your “Medrols”
05/15/2003	How fast is too fast for IV push medications?
05/01/2003	Nix the quick fix: Drug protocols require groundwork
04/17/2003	"Looks" like a problem: ephedrine - epinephrine
04/03/2003	U cnt abbrv “Patient Safety”
03/20/2003	Last week was National Patient Safety Week – and what a week it was!
03/06/2003	The virtues of independent double checks – they really are worth your time!
02/20/2003	It’s time for standards to improve safety with electronic communication of medication orders
02/06/2003	The reports are in…or are they? Awareness of medication error reporting programs needs a boost
01/23/2003	Water, water, everywhere, but please don't give IV
01/09/2003	Success with New Year's resolutions requires more than personal resolve
12/18/2002	"Cheers" for medication safety: Celebrating those who made a difference in 2002
11/24/2002	Watch out for this turkey - Complacency
11/13/2002	Face it! Intimidation presents serious safety issues
10/30/2002	Tricks but no treats: Illusions and medication errors
10/16/2002	It doesn't pay to play the percentages
10/03/2002	Benzocaine-containing topical sprays and methemoglobinemia
09/18/2002	Bad "marks" for order communication
09/04/2002	Involving non-clinical departments in patient safety discussions can reduce the risk of serious errors
08/21/2002	The road less traveled
08/07/2002	Accidental childhood acetaminophen overdoses illustrate our responsibility to educate parents
07/24/2002	Pain scales don't weigh every risk
07/10/2002 06/26/2002	Pharmacy interventions - Part I and II from ISMP survey
06/12/2002	What's in a name? Ways to prevent dispensing errors linked to name confusion A medication error trifecta!
05/29/2002	More on avoiding opiate toxicity with PCA by proxy
05/15/2002	Atrocious labeling of plastic ampuls needs action now by FDA and manufacturers
05/01/2002	Annenberg Conference sends a patient's message: "Nothing about me without me"
04/17/2002	Remote order entry: Innovative practice to reduce distractions and offer 24-hour pharmacy service
04/03/2002	Beware of erroneous daily oral methotrexate dosing
03/20/2002	Practitioner access to the Internet: A necessity in a modern hospital
03/06/2002	ISMP survey shows drug companies providing fewer unit dose packaged medications
02/20/2002	Eliminating dangerous abbreviations and dose expressions in the print and electronic world
02/07/2002	"Smart" infusion pumps join CPOE and bar coding as important ways to prevent medication errors
01/23/2002	Shortsighted JC standard lacks understanding of pharmacist's role in prospective order review
01/09/2002	Messages in our mailbox
12/12/2001	The year 2001 at a glance: ISMP's medication safety "Cheers"
11/28/2001	IV connection to tracheostomy cuff inflation port reflects larger problem
11/14/2001	Supervision often a weak link in error prevention
10/31/2001	To promote understanding, assume every patient has a health literacy problem
10/17/2001	Failure Mode and Effects Analysis can help guide error prevention efforts
10/03/2001	Systems thinking: Tap into staff creativity to unleash innovation
09/19/2001	ISMP survey on perceptions of a nonpunitive culture produces some surprising results
08/08/2001	It's time for a new model of accountability
07/25/2001	The supermarkets do it - so why can't we raise the "bar" in health care?
07/11/2001	Patient safety is all about taking that extra step
06/28/2001	Insights into people will improve our safety systems.
06/13/2001	Medication error or professional judgement?
05/30/2001	New official interpretation of JC standard bans open access to pharmacy after hours
05/02/2001	Please Don't Sleep Through this Wake-Up Call Includes ISMP's table of dangerous medical abbrevations
04/18/2001	Lessons Lost by the Global Pharmaceutical Industry

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