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Medication Errors

Using chloral hydrate carries a risk of adverse events and compounding errors, and much of the available literature recommends using alternative sedatives for pediatric patients. But evidence regarding the efficacy of chloral hydrate and of alternative agents is conflicting.
Matthew Grissinger RPh, FASCP
Accidental IV administration of heparinized irrigation solution occurs frequently. Two cases from ISMP Canada offer some safe practice recommendations.
Matthew Grissinger RPh, FASCP
Implementing IT in medication-use systems reduces adverse drug events by decreasing human error. But over-reliance on technology can lead to automation bias and complacency.
Matthew Grissinger RPh, FASCP
Indication-based prescribing has many potential benefits, including preventing errors by reducing medication choices and assisting with medication reconciliation.
Matthew Grissinger RPh, FASCP
The familiar but ambiguous sigs on prescriptions are often of limited help to patients and pharmacists. Sometimes, the instruction to “use as directed” has resulted in serious errors.
Matthew Grissinger RPh, FASCP
Neuromuscular blockers have been inadvertently administered to patients who were not receiving proper ventilatory assistance, causing death or permanent injuries.
Matthew Grissinger RPh, FASCP

Incorrectly prescribed medications can have serious implications, especially in young children. Safe practice recommendations include listing patients’ age, weight, and date of birth on prescriptions, verifying discharge orders, and involving pharmacists in reconciliation.

Matthew Grissinger RPh, FASCP

Part 1 of a 3-part series discusses 3 medication safety risks that can easily fall off the radar screen in hospitals and doctors’ offices.

Matthew Grissinger RPh, FASCP

Managing home infusion patients in the hospital and emergency department

Matthew Grissinger RPh, FASCP

Preventing incidents of oral meds given intravenously

Matthew Grissinger RPh, FASCP

Errors with flecainide suspension in children

Matthew Grissinger RPh, FASCP

Harm and death associated with methotrexate errors

Matthew Grissinger RPh, FASCP

Container mix-ups and syringe swaps in the surgical environment

Matthew Grissinger RPh, FASCP

The absence of a drug–disease interaction alert leads to a child’s death

Matthew Grissinger RPh, FASCP

Leftover or improperly discarded drugs are easy prey for diversion and are fueling the opioid abuse epidemic. ISMP offers safe practice recommendations to prevent drug misuse.

Matthew Grissinger RPh, FASCP

The final part of a 3-part series discusses medication safety risks related to labeling, patient education, and medication storage.

Matthew Grissinger RPh, FASCP

Part 2 of a 3-part series discusses medication safety risks related to labeling, patient education, and medication storage.

Matthew Grissinger RPh, FASCP

Inpatients with Parkinson’s disease require precise medication management

Matthew Grissinger RPh, FASCP

“Wrong patient” insulin pen injections alarmingly frequent

Matthew Grissinger RPh, FASCP

Diluting IV drugs in patient-care areas adds undue risk

Matthew Grissinger RPh, FASCP

Strengthen your resolve: no unlabeled containers anywhere, ever!

Matthew Grissinger RPh, FASCP
A False Alarm Can Have Real Consequences

Unverified patient-reported errors can have real consequences

Matthew Grissinger RPh, FASCP

Speaking “off the cuff” is a prescription for disaster in health care

Matthew Grissinger RPh, FASCP
Twelve Persistent Safety Gaffes That We Need to Resolve

Twelve persistent safety gaffes that need resolution

Matthew Grissinger RPh, FASCP

Practice changes cause the mislabeling of batched drugs

Matthew Grissinger RPh, FASCP
Its Impact, Why It Arises and Persists, And How to Address It—Part 2

The impact of disrespectful workplace behavior and how to address it

Matthew Grissinger RPh, FASCP

Epinephrine for anaphylaxis: Autoinjector or 1-mg vial or ampoule?

Matthew Grissinger RPh, FASCP

Safety requires mindfulness

Matthew Grissinger RPh, FASCP

Misidentification of alphanumeric symbols plays a role in errors

Matthew Grissinger RPh, FASCP
Practitioners Speak Up (Again)—Part 1

Survey reveals widespread health workplace intimidation

Matthew Grissinger RPh, FASCP

Improve staff training with vendor partnerships

Matthew Grissinger RPh, FASCP

Inadvertent intrathecal vincristine administration causes fatalities

Matthew Grissinger RPh, FASCP

We all have a role in preventing fentanyl patch tragedies

Matthew Grissinger RPh, FASCP

Muting alarms in the post-anesthesia care unit endangers patient safety

Matthew Grissinger RPh, FASCP

We must ensure safer use of oral chemotherapy

Matthew Grissinger RPh, FASCP

Improving medication safety during transitions in care.

Matthew Grissinger RPh, FASCP

Understanding IV container overfill promotes safety.

Matthew Grissinger RPh, FASCP

Automated dose alerts with hard stops aid patient safety.

Matthew Grissinger RPh, FASCP

Preventing fatal PCA adverse events

Matthew Grissinger RPh, FASCP

Using a saline flush “site unseen” could lead to a wrong-route error

Matthew Grissinger RPh, FASCP

Risk-reduction strategies for high-alert medication lists

Matthew Grissinger RPh, FASCP

Community liaison programs to cut hospital readmissions

Matthew Grissinger RPh, FASCP

An ISMP survey finds problems involving proper use of Carpuject prefilled syringes.

Matthew Grissinger RPh, FASCP

A culture of respect is vital to providing health care safely.

Matthew Grissinger RPh, FASCP
Error-Prevention Strategies for This Strong Iodine Solution

Safety strategies for avoiding tragedies with Lugol’s solution

Matthew Grissinger RPh, FASCP

Mismatched prescribing and pharmacy templates for parenteral nutrition can cause errors.

Matthew Grissinger RPh, FASCP

Bulk packages of IV contrast media used inappropriately

Matthew Grissinger RPh, FASCP

Pharmacy focus on hospital discharge cuts readmissions.

Matthew Grissinger RPh, FASCP
Interruptions Lead to Errors and … Wait, What Was I Doing?
Interruptions and distractions can sidetrack patient safety.
Matthew Grissinger RPh, FASCP

Smart pump concentration mistakes can lead to harm.

Matthew Grissinger RPh, FASCP

A clinical reminder about the safe use of insulin vials

Matthew Grissinger RPh, FASCP
Red Flags That Represent Credible Threats to Patient Safety

The index of suspicion: red flags warn of safety threats.

Matthew Grissinger RPh, FASCP

Physician dispensing in offices and clinics raises concerns.

Matthew Grissinger RPh, FASCP
Multiple latent failures align to harm a patient seriously.
Matthew Grissinger RPh, FASCP

We often abandon the “second victims” of medical errors

Matthew Grissinger RPh, FASCP
A Patient Verification Process is Needed Everywhere, Not Just at the Bedside
Verification of patient identity is needed at all stages.
Matthew Grissinger RPh, FASCP
Take steps to prevent ingestion or aspiration of objects
Matthew Grissinger RPh, FASCP
Conservative prescribing can improve medication safety.
Matthew Grissinger RPh, FASCP
Your Actions Speak Louder Than Words When It Comes To Patient Safety
Actions on patient safety speak louder than words.
Matthew Grissinger RPh, FASCP
For warnings, “do this” may be better than “don’t do that.”
Matthew Grissinger RPh, FASCP
Height and weight errors confound electronic prescribing.
Matthew Grissinger RPh, FASCP
How to avoid patient harm from a magnesium bolus dose
Matthew Grissinger RPh, FASCP

Another tragic parenteral nutrition compounding error

Matthew Grissinger RPh, FASCP

Measuring mix-ups blamed for overdoses of insulin

Matthew Grissinger RPh, FASCP
Here’s Why You Should Tell Stories, Too …
Telling true stories can help improve medication safety.
Matthew Grissinger RPh, FASCP
Following the guidelines for standard order sets minimizes incorrect prescribing.
Matthew Grissinger RPh, FASCP
Mixups with local and topical epinephrine have led to fatalities.
Matthew Grissinger RPh, FASCP
Can Cross-Contamination Be Avoided?
Sharing metered dose inhalers among patients can lead to cross-contamination.
Matthew Grissinger RPh, FASCP
Preventing acute hyponatremia in hospitalized children
Matthew Grissinger RPh, FASCP
Generic drugs with multiple brand names can cause confusion.
Matthew Grissinger RPh, FASCP
Potential problems with pain pumps
Matthew Grissinger RPh, FASCP

Preventing mistakes with color-tinted intravenous tubing

Matthew Grissinger RPh, FASCP
Borrowing and lending drugs is a dangerous business.
Matthew Grissinger RPh, FASCP
The Result: Drug Orders Are Omitted
Drug orders can be accidentally omitted or misread if a scanner pulls too many pages through at once.
Matthew Grissinger RPh, FASCP
Avoiding Pitfalls in Conducting a Root Cause Analysis
Avoiding pitfalls when conducting a root cause analysis
Matthew Grissinger RPh, FASCP
Vigorous Monitoring Is Crucial

Avoiding dangerous lapses in infection-control practices

Matthew Grissinger RPh, FASCP
Giving medications though enteral feeding tubes can be fraught with danger.
Matthew Grissinger RPh, FASCP

Using a parenteral syringe to prepare or give oral or enteral liquids can be deadly

Matthew Grissinger RPh, FASCP
Automated dispensing cabinets have had a mixed record on improving drug safety.
Matthew Grissinger Rph, FaScp
Mixups of epidural and intravenous drugs can be deadly.
Matthew Grissinger RPh, FaScP
The physical design of an organization’s workspace can enhance or diminish patient safety.
Matthew Grissinger RPh, FASCP
Overcoming Bystander Apathy
Matthew Grissinger RPh, FASCP
Matthew Grissinger RPh, FASCP
Methods to improve recognition of look-alike alphanumeric characters
Matthew Grissinger RPh, FASCP
Basal opioid infusions may raise the risk of respiratory depression when given with patient-controlled analgesia.
Matthew Grissinger RPh, FASCP
What Captures Your Attention?
Many mistakes can result from “inattentional blindness.”
Matthew Grissinger RPh, FASCP
Matthew Grissinger RPh, FASCP
Matthew Grissinger RPh, FASCP
Confusion of Micrograms With Milligrams
Matthew Grissinger RPh, FASCP
Applying the Lessons Learned Can Save Lives
Matthew Grissinger RPh, FASCP