Michael J. Gaunt, PharmD

The Institute for Safe Medication Practices (ISMP) has released its 2022-2023 Targeted Medication Safety Best Practices for Hospital, with which it aims to address problems that continue to cause fatal and harmful errors despite repeated warnings in ISMP publications.

Although the best practices might be challenging for some organizations to achieve, they are all practical and realistic and their value in reducing medication errors is grounded in expert analysis and/or scientific research on medication errors and their causes. Their implementation can vastly improve medication safety and reduce the risk of significant patient harm.

Although created for hospitals, the best practices are often applicable to other health care settings.

First released in 2014, the list, which originally included 6 best practices, is updated every 2 years and now comprises 19 best practices, including 3 newly introduced:

Avoid bringing oxytocin infusion bags to the patient’s bedside until it is prescribed and needed.

Provide oxytocin in a ready-to-use form. Boldly label both sides of the infusion bag to differentiate oxytocin bags from plain hydrating solutions and magnesium infusions.

Require the use of standard order sets for prescribing oxytocin antepartum and/or postpartum that reflect a standardized clinical approach to labor augmentation or induction and control of postpartum bleeding.

 Standardize how oxytocin concentration, doses, and rates are expressed. Communicate orders for oxytocin infusions in terms of the dose rate (eg, milliunits/minute) and align with the smart infusion pump dose error-reduction system.

Standardize to a single bag or concentration size for both antepartum and postpartum oxytocin infusions, such as 30 units in 500 mL lactated Ringer’s.

Maximize the use of barcode verification prior to medication and vaccine administration by expanding the use beyond inpatient care areas.

Regularly review compliance and other metric data to assess effectiveness and use of this safety technology, such as acknowledged or bypassed alerts and scanning compliance rates.

Specifically target clinical areas with an increased likelihood of a limited or short patient stay, such as catheterization laboratories, dialysis centers, emergency departments, infusion clinics, and labor and delivery, outpatient, perioperative, and radiology areas.

Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications.

Avoid reliance on low-leverage risk-reduction strategies, such as applying high-alert medication labels on pharmacy storage bins and providing education, to prevent errors, and instead bundle these with high- and mid-leverage strategies.

Ensure that the strategies address system vulnerabilities in each stage of the medication-use process (ie, prescribing, dispensing, administering, and monitoring) and apply to nurses, pharmacists, prescribers, and other practitioners involved in the medication-use process.

Establish outcome and process measures to monitor safety and routinely collect data to determine the effectiveness of risk-reduction strategies.

For each medication on the facility’s high-alert medication list, outline a robust set of processes for managing risk, affecting as many steps of the medication-use process as feasible.

Limit the use of independent double-checks to select high-alert medications with the greatest risk for error within the organization, such as chemotherapy, heparin and opioid infusions, and intravenous insulin.

Regularly assess for practices used to support the safe use of medications and risk in the systems by using information from external and internal sources, such as The Joint Commission and the ISMP.

The following supplemental information is included in the rationale section of Best Practice 1: Dispense vincristine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe. This was added: “In 2020, the US Food and Drug Administration (FDA) changed the prescribing information (package insert) to call for dilution in a minibag only (www.ismp.org/ node/18548). The labeling for vincristine now states: To reduce the potential for fatal medication errors due to incorrect route of administration, vincristine sulfate injection should be diluted in a flexible plastic container and prominently labeled as indicated ‘For intravenous use only—fatal if given by other routes.’ Preparation and administration of the drug in a syringe has been removed from the package insert.”

Health systems and hospitals should focus their medication safety efforts over the next 2 years on these 2022-2023 best practices, and other health
care providers can learn from them. The rationale for recommending the best practices, along with related ISMP guidelines and publications for additional information, is found in the full best practices document.

 Related documents that might be helpful to hospitals include frequently asked questions

 that can help these institutions identify gaps in implementation of these best practices and develop an action plan to address vulnerabilities.

, is a medication safety analyst and the editor of ISMP Medication 

 Community/Ambulatory Care Newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

1. Targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. February 9, 2022. Accessed February 14, 2022. www.ismp.org/guidelines/best-practices-hospitals

2. Frequently asked questions - targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. Accessed February 14, 2022. www.ismp.org/tmsbp/faq

3. Worksheet for the targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. February 9, 2022. Accessed February 14, 2022. www.ismp.org/resources/worksheet- ismp-targeted-medication-safety-best-practices-hospitals

Articles

Although the ISMP created the guidelines for hospitals, they are applicable in other health care settings.

Implement These 3 Targeted Best Practices

High-alert medications are drugs that carry a heightened risk of causing significant patient harm when they are used in error.

Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. This is borne out repeatedly by reports submitted to the Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (MERP).

Based on error reports submitted to MERP, input from practitioners and safety experts, and reports of harmful errors in the literature, the institute has revised and updated the ISMP List of High-Alert Medications in Community/Ambulatory Care Settings.

The ISMP is relying on ambulatory-care and community settings to use this updated list as a resource to identify the high-alert medications prescribed, stored, dispensed, and/or administered in their organizations or the facilities they serve. However, this is just the first step in safeguarding the use of high-alert medications. Without highly effective processes for staff members to follow to detect and prevent errors, a list will do little to increase medication safety. Similarly, a list of high-alert medications and related risk-reduction strategies that are not well understood by all staff members will have little impact on safety.

The purpose of identifying high-alert medications is to establish specific safeguards to reduce the risk of harm with these drugs in all phases of the medication-use process. Strategies should eliminate or prevent the errors, make the errors visible, and/or mitigate the harm from errors when they occur. To be effective, the following components must be considered:

 Effective strategies must address the underlying system-based causes of errors with each type of high-alert medication or class of medications. To learn about the causes of errors, review internal medication error reporting data and the results of any applicable root-cause analyses. Equally important, a search of the external literature should be completed to learn about errors with high-alert medications that have occurred elsewhere. Pharmacies must take steps to understand the causes of errors in the facility. If a pharmacy cannot describe how errors happened, its strategies may not be effective at targeting the risks within the organization.

 A single risk-reduction strategy for each high-alert medication is rarely enough to prevent harmful errors. The keys to success include the following components:

A variety of risk-reduction strategies should be used simultaneously to reduce the risks associated with a particular high-alert drug. David Marx, a culture and system reliability expert, likens the relative safety of a system to a dice game, with each die representing a risk-reduction strategy in the layer of the safety net.

 Rolling a snake eye, or 1, represents failure; rolling anything else represents success. The more dice rolled, the less the risk of getting all 1s, and the safer the system will be. As noted by Marx, “in no place is the single [die] more deadly than that of health care....”

 Roll a single die, and harm is only a single failure away. Design the safety system to be a third, fourth, or fifth roll of the dice away from harm.

Choose strategies that provide reliable protection each time, such as automation or technology alerts, and limit reliance on strategies that require staff members to follow policies or rules or rely on memory to avoid error.

Risk-reduction strategies should affect as many steps of the medication-use process as feasible, given the underlying causes.

The best strategies will be sustainable over time.

A list of high-alert medications and associated risk-reduction strategies that is not well known to all who touch the medication-use process will have little impact on patient safety. Be sure to discuss with all staff members why the list and strategies are important, why they were created, and who they will affect. This will help staff members understand the value of the list and strategies, the medication errors and patient harm they will prevent, and why it is critical to implement each risk-reduction strategy. Make the document electronic and mobile friendly so that staff members can easily access it and quickly search it whenever needed.

Routinely audit the practice to determine the effectiveness of risk-reduction strategies for the identified high-alert medications. Also, regularly ask staff members for feedback and ideas about the high-alert medication list and associated risk-reduction strategies. Find out any concerns they may have at staff meetings, during leadership meetings, and/or via anonymous surveys. This is essential to keep all staff members engaged and to become aware of any barriers to implementing the risk-reduction strategies. Use this information to make necessary adjustments to the list and strategies.

, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

1. High-alert medications in community/ambulatory care settings. Institute for Safe Medication Practices. September 30, 2021. Accessed February 18, 2022. www.ismp.org/recommendations/ high-alert-medications-community-ambulatory-list

2. Marx D. Play with three dice, when you can. Outcome Engenuity. Accessed February 18, 2022. https://www.outcome-eng.com/ play-three-dice-can/

Implementation, communication, and assessment are critical steps to ensure patient safety.

High-Alert Medication List Is Effective When Combined With Risk-Reduction Strategies

Since the FDA authorized emergency use of the pediatric Pfizer-BioNTech COVID-19 vaccine for children aged 5 to 11 years on October 29, 2021, the Institute for Safe Medication Practices (ISMP) has received hundreds of reports involving mix-ups between the formulation for individuals 12 years or older and the pediatric formulation.

Most of the mix-ups have occurred in ambulatory or outpatient care settings, such as community pharmacies, outpatient clinics, physician offices, and public health clinics. The errors have resulted in wrong doses for children aged 5 to 11 years (over- and underdoses) and 12 years or older (underdoses). In response, a National Alert Network alert was issued on December 6, 2021, to raise awareness and recommend ways to prevent errors.

Some of the errors submitted to the ISMP have involved syringe or vial mix-ups. The pediatric formulation (10 mcg/0.2 mL after dilution) of the Pfizer-BioNTech COVID-19 vaccine is supplied in a multiple-dose vial with an orange border on the label and an orange cap. The formulation for individuals 12 years and older has a purple cap. The pediatric formulation label states “Age 5y to <12y” (Figure

), but this is not as prominent as “Dilute Prior to Use” and could be missed. In addition, the dose in mcg is not listed on the label, which would be helpful in differentiating this product from the 30 mcg/0.3 mL formulations for patients 12 years and older.

Although different color caps on the Pfizer-BioNTech COVID-19 vaccines might help prevent some mix-ups, once the cap is removed and discarded, doses sometimes are prepared one at a time rather than all at once, which would render the cap color irrelevant. Also, it is unlikely that the vial would accompany prepared syringes, so the vial label cannot be verified by those administering the vaccine or parents or patients receiving the vaccine.

In other reported cases, the formulation intended for individuals 12 years and older was used for children aged 5 to 11 years, as it was thought to be acceptable if only 10 mcg was given, either as 0.1 mL of the 30 mcg/0.3 mL vaccine (10 mcg) or by diluting the 10-mcg dose in a syringe to 0.2 mL. However, neither method is correct, as either too little or too much vaccine would likely be injected. The pediatric vaccine is specifically formulated to be more diluted to ensure accurate measurement. The vaccine formulated for individuals 12 years and older should never be used to prepare doses for children aged 5 to 11 years.

Other factors contributing to these vaccine mix-ups include high patient volume, vaccinators being unaware of the proper dose for a child based on their age, vaccinators failing to correctly identify or verify the patient’s age, and vaccinators not knowing that a pediatric formulation exists.

Here are some tips to ensure that the right doses are administered.

Ask the parent or patient to provide 2 patient identifiers at the pharmacy counter or when checking in a patient to receive a vaccine: their full name and date of birth.

 Repeat this process immediately prior to vaccine administration. For pediatric patients, also verify the patient’s actual age with the parent or caregiver, and ask which vaccine(s) they have requested.

Bring only the intended, labeled vaccine syringe(s) for 1 patient into the vaccination area at a time.

 Involve the parent or patient in verifying the vaccine by reading the label to confirm the correct vaccine.

Clearly label all individual syringes containing vaccines.

 To facilitate this labeling, print labels for each patient or provide vaccine preparers with sets of preprinted labels that differentiate the doses for individuals 12 years and older and pediatric patients.

Document the vaccine expiration date, or date of manufacture, and lot number prior to vaccine administration.

 Then document administration afterward in the patient’s profile, on vaccination records, and via state or other immunization registries.

 Ideally, staff should not be expected to accomplish both regular dispensing functions and vaccine administration simultaneously.

Report all vaccine errors internally and to the FDA/CDC Vaccine Adverse Event Reporting System, which is mandatory for COVID-19 vaccine errors under an Emergency Use Authorization.

 The ISMP also asks providers to report vaccine errors to the ISMP National Vaccine Errors Reporting Program.

Segregate and store the vaccines that are organized and properly labeled in freezers or refrigerators.

 Store the COVID-19 vaccines for individuals 12 years and older separately from the pediatric vaccines.

Use barcode scanning whenever possible to verify that the correct product has been retrieved during the production and/or verification phase of the dispensing process.

 Ideally, prior to administration, barcode scanning should again confirm the correct vaccine.

, is a medication safety analyst and the editor of 

ISMP Medication Safety Alert! Community/Ambulatory Care

 newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

1. Age-related COVID-19 vaccine mix-ups. Institute for Safe Medication Practices. December 6, 2021. Accessed January 14, 2022. https://www.ismp.org/alerts/age-related-covid-19-vaccine-mix-ups

2. Vaccine Adverse Event Reporting System. US Department of Health and Human Services. Accessed January 14, 2022. https:// vaers.hhs.gov/

3. Report an error. Institute for Safe Medication Practices. Accessed January 14, 2022. https://www.ismp.org/report-medication-error

Institute for safe medication practices receives hundreds of reports of incorrect doses for children.

Be Aware of Age-Related Mix-Ups of COVID-19 Vaccines

A pharmacy using automated dispensing technology (such as a vial-dispensing robot) was refilling a cell with trazodone 50-mg tablets. The individual refilling the machine had retrieved two 500-count medication bottles from a storage shelf without realizing that one held topiramate 50 mg, not trazodone 50 mg. Both medications are manufactured by Zydus Pharmaceuticals. 

The bottles for both look nearly identical (Image 1), and one was stored right behind the other. Both tablets also look similar—about the same size, round, and white (Image 2). Fortunately, before any patients received the wrong medication, a pharmacist caught the error while verifying a prescription for trazodone 50 mg when she recognized that the 2 drugs appeared to be mixed in the prescription vial.

The pharmacist who reported the error said the automated dispensing technology software her store uses requires barcode scanning; however, unless each stock bottle is scanned individually, the technology can be bypassed by scanning a single bottle. So if an individual is trying to add 1000 tablets and the medication comes in a 500-count bottle, which is how both medications in this situation are supplied, the employee can scan 1 bottle and pour both—including the incorrect medication in the unscanned bottle—into the dispensing robot cell. Because of what happened, the pharmacy now requires use of only 1 bottle at a time to restock the robot.

Pharmacies with robotic dispensing capabilities must address situations in which multiple bottles of tablets are used to refill a single cell. Visual checks are important, but as described above, they cannot be solely relied upon for proper identification of bottle contents. 

Check with the technology manufacturer to learn what is recommended for addressing situations in which multiple bottles are used to refill a cell. Ideally, the filling process should require a scan of the barcode printed on the label of each stock bottle before its contents are added. Pharmacies should engage their staff members and establish standard work practices to barcode scan each stock bottle. Use only unopened stock bottles to ensure the National Drug Code number, lot number, and expiration date match for all tablets (2D barcodes would be needed). Completing the entire process of filling a cell before moving to the next and the corresponding drug bottle(s) is critical to ensure that bottles used to refill different cells are not mixed up after barcode verification. Authorizations to make any changes in the bin contents of automated dispensing systems should be restricted to properly trained staff members. 

Pharmacy managers and/or regional personnel for chain pharmacies should periodically perform quality-control checks by observing the processes involving automation and robotics to ensure adherence to the standardized work practices. If at-risk behaviors, such as scanning only 1 bottle or scanning the same bottle twice, are observed, coach staff members to see the potential for error and the importance of scanning each bottle. Finally, share stories like this with staff members who use this type of automation to emphasize best practices, such as the scanning of each bottle rather than 1 bottle multiple times.

It is also undeniable that look-alike product labeling and packaging was a root cause of the mix-up. The Institute for Safe Medication Practices (ISMP) recommends reading medication labels 3 times at different points in the product selection and dispensing processes: when obtaining a drug from storage, during use, and when discarding the container or returning it to stock. However, the need for companies to prevent container labels from looking similar across multiple items within a company’s product line is among the topics included in draft guidance for industry from the FDA’s Center for Drug Evaluation and Research in Safety Considerations for Container Labels and Carton Labeling Design to Minimize Medication Errors.1 The ISMP has asked Zydus to revise the product labeling that contributed to this error and look at all its product labels for such safety issues.

The ISMP hopes to address the safe use of automated dispensing technology more globally. Please share with the ISMP any identified barriers or limitations experienced in the safe use of automated dispensing technology, including limitations in the barcode scanning process. Please also share any strategies in place to ensure the correct drug is added to the correct cell and reduce the risk of medication errors. Share information with the ISMP via email (ismpinfo@ismp.org).

Center for Drug Evaluation and Research. Guidance for industry: safety considerations for container labels and carton labeling design to minimize medication errors. Docket number: FDA- 2013-D-0401. April 2013. Accessed November 11, 2021. https:// www.fda.gov/regulatory-information/search-fda-guidance-documents/safety-considerations-container-labels-and-carton-labeling-design-minimize-medication-errors

Pharmacies should address situations in which multiple bottles of tablets are used to refill a cassette.

Ensure the Safe Use of Automated Dispensing Technology

An influx of reports involving transdermal medication patches submitted to the Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (MERP) prompted ISMP to look at all patch-related reports it had received within the past 4 years.

More than 50 reports associated with 12 different transdermal medication patches were analyzed. Patches most frequently involved in reported errors included clonidine (n = 10), estradiol (n = 6), fentanyl (n = 16), and scopolamine (n = 7). Three of the error types identified during the analysis are described below.

The ISMP has received 7 reports associated with practitioners failing to identify patches on the patient’s or resident’s skin (which had been applied prior to admission), finding multiple patches on patients that had been left on longer than prescribed, and/or not removing an old patch when applying a new patch. Five of these events involved fentanyl patches. In 1 case, 2 patches were found on an unexpectedly somnolent patient during rounds. In another case, 3 100-mcg/hour fentanyl patches were found on an oversedated patient with respiratory depression. We have also received reports of finding multiple nicotine patches and rivastigmine (Exelon) patches used to treat Alzheimer disease on patients during their admission. Because many patches are beige or clear, they might easily be missed on the skin of some patients.

The ISMP received 6 reports of dispensing the wrong dose of patches that are available in more than 1 strength. One of these errors was 

®. An order for 50-mcg/hour fentanyl patches included “72 hours” for the duration of patch application. The “72” was mistaken as the strength, leading to the erroneous dispensing of a 75-mcg/hour instead of the intended 50-mcg/hour fentanyl patch. Including the duration of controlled drug delivery (ie, 72 hours) in the order and the drug description field contributed to this dispensing error. In another event, a pharmacy technician filling an order for rivastigmine patches 9.5 mg/24 hour for a long-term care (LTC) resident prepared 13.3-mg/24-hour patches and failed to notice the error because he had bypassed he usual barcode scanning process. The pharmacist verifying the product did not notice a discrepancy between the 13.3-mg/24-hour patches and the image of the 9.5-mg/24-hour patches on the computer screen and dispensed the patches.

Patch Cover Applied Without Medication Patch

The ISMP received 5 reports of applying a clonidine patch adhesive cover directly to the skin without first applying the clonidine patch. In 1 case, only the adhesive cover was retrieved from the carton and applied. In all other cases, the active medication patch was accidentally discarded. The errors contributed to uncontrolled blood pressure. The clonidine transdermal system (Catapres-TTS) is packaged in a carton containing individually labeled pouches of 4 clonidine patches and 4 adhesive covers. Once removed from the pouches, the clonidine patch is a different color, shape, and size than the adhesive cover, but the patch and cover do not specify which is which. Application of the adhesive cover is optional. The cover should be applied directly over the clonidine patch only if the patch begins to separate from the skin.

Treating patients receiving medication patches can be challenging, given the variety of patch characteristics. To prevent the types of errors described above, consider the following recommendations:

• Build a medication administration record note to remind LTC nurses to apply the clonidine medication patch and not just the cover. If the adhesive cover is used over the medication patch, it is best for nurses to label the adhesive cover with the drug name, strength, and date, before applying it.

• Create electronic prescribing medication patch order sentences that include the appropriate application frequency.

• Dispense the clonidine medication patch and adhesive cover in a zipper storage bag with a label explaining the 2 components of the product for LTC patients.

• Do not include the duration of medication delivery in the patch drug description field, which could be confused as the dose, for fentanyl patches. The patient’s dosing instructions should communicate the frequency of changing the patch.

• Employ barcode scanning during dispensing to ensure correct product selection.

• Explore ways to assist patients to maintain an up-to-date record of all their medications (including any OTC products and patches), such as providing them with a current medication list at each encounter.

• Give LTC nurses a documentation prompt each shift to verify placement of each medication patch and to record the location, if necessary.

• Provide verbal and written education to care- givers and patients about the use of patches. Verify the patient’s understanding of the information.

• Use scripted prompts or questions to collect a detailed medication history from each patient. Specifically ask patients about the use of any type of patch.

Clonidine, Estradiol, Fentanyl, and Scopolamine are involved most frequently, an ISMP review shows.

Watch for 3 Types of Errors With Transdermal Patches

A patient, who had been hospitalized after suffering a stroke, died following an inadvertent infusion of fentanyl.

Although the patient’s condition at first had improved, he later developed difficulty swallowing. After aspirating food and suffering acute respiratory arrest, the patient was placed on a ventilator, during which he was sedated via an intravenous (IV) fentanyl infusion (10 g/mL) connected to 1 of multiple channels on a smart infusion pump. Over the next several days, the patient received fentanyl, ranging from 25 to 100 g per hour, with the dose titrated daily as needed for sedation. Several days later, the patient’s physician discontinued the fentanyl infusion in the morning, hoping to extubate the patient that afternoon. The pump channel infusing the fentanyl was turned off, but the infusion container was left in place and remained connected to the patient’s IV line.

Later that day, the smart infusion pump alarm went off, alerting practitioners that a bag of Lactated Ringer’s, which was infusing via a different pump channel, was near completion. A nurse filling in for the patient’s primary nurse responded to the pump alarm, turned off the corresponding pump channel, retrieved a new Lactated Ringer’s infusion, attached it to the correct pump channel, and programmed the infusion correctly. However, she accidentally restarted the fentanyl infusion instead of the Lactated Ringer’s solution. Although the pump alarm went off, the nurse silenced it, thinking that it had happened accidentally. An evening nurse caring for the patient also did not notice that fentanyl, not Lactated Ringer’s, was infusing. The rate of the fentanyl infusion was not disclosed.

Several hours later, the patient’s blood pressure had dropped significantly, and the error was recognized. Although the fentanyl infusion was then quickly discontinued, the prolonged hypotension caused by the fentanyl infusion caused serious brain and organ anoxia and ultimately resulted in the patient being removed from life support several days later.

Although the Institute for Safe Medication Practices (ISMP) has no additional details other than what could be gathered through the news media, there are several risk-reduction strategies that might have pre- vented this error.

 Require oncoming nurses to verify all their assigned patients’ infusions, tracing the lines and inspecting the pump settings and infusion labels, and then matching each with orders. The oncoming nurse and the nurse finishing her shift should perform this verification process together.

Disconnect and discard all discontinued or held infusion bags/ syringes

. Discontinued or held infusions should be immediately removed from the pump, disconnected from the patient, and discard- ed. A discontinued infusion should not be left set up via a stopped infusion pump that either remains connected to the patient and/or hanging on the patient’s IV pole at bedside. Also, the tubing should be changed to ensure no residual medication is left that could be inadvertently administered as a bolus when the tubing is used to administer other fluids and medications.

. Implement bidirectional (ie, autodocumentation and autoprogramming) smart infusion pump interoperability with the electronic health record to reduce the risk of pump programming errors.

. Labels with the name of the drug being infused and route of administration should be affixed to each access line (eg, epidural and IV) at the distal end of the tubing closest to the patient and on the tubing above the channel or pump. If available as a pump feature, ensure the name of the infusion is clearly visible on the pump screen.

. For a variety of reasons such as alert fatigue or poor warning design, operational alarms may be overlooked or quickly overridden. To maximize efficiency and response to operational alarms, establish thresh- olds for duration and frequency, identify the top alarms by type and care area/profile, and deter- mine whether they are critical alerts. Remove non- critical alerts as needed to decrease alert fatigue.

. When parenteral infusions are changed (new bag or syringe), reconnected, or started or the rate is adjusted, the tubing should be traced by hand from the solution container to the pump and then to the patient for verification of the proper channel/pump and route of administration.

 is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

Evans T. Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. 

. Updated October 31, 2020. Accessed September 8, 2021. 

www.indystar.com/story/news/investigations/2020/10/30/drug-error-cancer-researcher-eskenazi-hospital-killed/5979448002/

Discontinued fentanyl infusion left attached to patient contributes to his death, but risk-reduction strategies can prevent similar mistakes.