Medication Safety Alert! June 1, 2017
In this week's issue:
- Common Missteps with Medication Safety: Rolling a Single Dice, Ineffective Strategies, and Unexecuted Action Plans
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- ISMP survey on 2016-2017 Targeted Medication Safety Best Practices
- Safety of EPINEPHrine kits during prefilled syringe shortage
- Dispense a needle with that pen
- Med wreck?
An intravenous (IV) line mix-up in a hospital reoccurred within a few months despite what was thought to be an effective action plan after the initial event. After the first event, an interdisciplinary team had conducted a thorough investigation, identified the causal factors, and developed an action plan hoping to reduce the risk of similar errors. After the second event, the hospital team again conducted a thorough investigation of the event, and then carefully reassessed its previous action plan. In the process, the team gained significant insight into what ISMP has identified as four...