CLINICAL ROLE -
Obstetrical Patient Dies After Inadvertent Administration of Digoxin for Spinal Anesthesia
The ampule of digoxin was accidentally taken from automated dispensing cabinet instead of bupivacaine
Read More
Recent Vaccine Approvals Present New Potential Errors
Prefilled diluent and vaccine syringes may be easily mixed up
Implement Strategies Now to Prevent Patient Death From Accidental Daily Methotrexate Dosing
Specifying a day of the week to take the medication could help avoid inadvertent daily dosing
Avoid Wrong-Route Errors With Tranexamic Acid
Although the brand name manufacturer updated the label after the FDA’s request, generic manufacturers have not all followed suit.
Maximizing REMS Potential to Reduce Risk of Errors, Patient Harm
Incorporate Program Requirements Into Systems and Workflows.
Look-Alike Packaging, Drug Shortages Continue to Contribute to Medication Errors
Because the generic name of both the timolol once-daily and twice-daily formulations is the same, pharmacies should only carry 1 formulation.
Avoid Errors by Checking Patients’ Medications Lists
Inaccurate information, miscommunication during transition points can have dire consequences.
Nurses Experience Needlestick Injuries With Evenity Syringe Needle
Errors risk transmission of blood-borne pathogens, including HBV, HCV, HIV, to health care providers, patients.
Misconnection of Devices to IV Tubing Can Be Fatal
Death occurs from air embolism after pneumatic line was connected to an intravenous catheter.
Help Specialty Pharmacy Patients Access Out-of-Stock Drugs
Establish procedures, including training employees, to address shortages, back-order situations.
Education Can Prevent Mix-ups Between Adult, Pediatric Biktarvy Products
Clinical decision support, packaging changes can help stop errors related to the HIV medication.
Multichamber Bag Parenteral Nutrition Poses Risks
Learn strategies to safeguard use of the intravenous administration products to protect patients.
Consider 2 Safety Issues When Treating, Vaccinating for Monkeypox
Protect patients by evaluating VIGIV concentration and avoiding tearing of metal flange on vaccine vial.
Communication, Workflow Vulnerabilities Cause Errors
Pharmacists should engage patients, explore system fixes to prevent missed drug-drug interactions
Be Wary of the Wrong Dosing Unit Being Used in Directions
Specialty pharmacy reports case of alirocumab prescription with mg incorrectly typed instead of mL.
Mitigate Risk for Errors Involving Paxlovid
Take steps to safeguard prescribing, dispensing, and patient use of the COVID-19 antiviral medication.
Prevent Drug Interactions With Paxlovid
Resources for health care professionals include FDA’s patient eligibility screening checklist tool for prescribers.
Patients Swallow the Desiccants in Everolimus Blister Cards
Mark these products for mandatory patient education on the cartons and in the pharmacy computer system.
Infant’s Mom Discovers Wrong Directions on Pediatric Propranolol Oral Liquid Label
Case highlights the need to stop, listen, and investigate when patients or parents express a safety concern.
Copying an Old Prescription May Lead to Trouble
Expediting the dispensing process makes sense, but take care when entering and verifying script.
Implement These 3 Targeted Best Practices
Although the ISMP created the guidelines for hospitals, they are applicable in other health care settings.
High-Alert Medication List Is Effective When Combined With Risk-Reduction Strategies
Implementation, communication, and assessment are critical steps to ensure patient safety.
Be Aware of Age-Related Mix-Ups of COVID-19 Vaccines
Institute for safe medication practices receives hundreds of reports of incorrect doses for children.
Ensure the Safe Use of Automated Dispensing Technology
Pharmacies should address situations in which multiple bottles of tablets are used to refill a cassette.
Watch for 3 Types of Errors With Transdermal Patches
Clonidine, Estradiol, Fentanyl, and Scopolamine are involved most frequently, an ISMP review shows.
Infusion Pump Errors Are Avoidable
Discontinued fentanyl infusion left attached to patient contributes to his death, but risk-reduction strategies can prevent similar mistakes.
Patients Report Confusion With Use of Alprostadil Urethral Inserts
Pharmacists should provide both verbal education and written instructions, so mistakes do not occur.
Concentrations of Ibuprofen Suspensions Are Error Prone
It is time to standardize to a single formulation to avoid mix-ups that can lead to adverse effects.
Labeling and Packaging Issues Contribute to Dose, Quantity Errors
Companies and practitioners should take important steps to protect patients from these mistakes.
Denial Is Not the Best Policy
When patients report pharmacy errors, respond with empathy and transparency to avoid alienating them.