Acute Care Volume 21, Issue 24

Medication Safety Alert! December 1, 2016

In this week's issue: 

  • Accidental Intravenous (IV) Infusion of Heparinized Irrigation in the Operating Room (OR)
  • Betaine anhydrous vs. betaine hydrochloride
  • Minibag volume confusion
Featured article

Problem: Accidental intravenous (IV) administration of a solution intended for bladder or wound irrigation is a repetitive error that has been the topic of numerous events published in this newsletter. These events typically involved confusion between unlabeled solutions on the sterile field, mix-ups between irrigation and parenteral solution bags, or mix-ups between irrigation and venous access lines during connection or reconnection of the solutions. These errors have happened both inside and outside the operating room (OR).

ISMP’s sister organization, ISMP Canada, recently published two...

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