Medication Error Alert
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subscribers about serious errors or information requiring immediate attention to ensure that the healthcare community has the opportunity learn about emerging safety issues in real time. Beginning in 2009, ISMP joined with the other members
Medication Errors In Hospitals Stories
of the National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP) medication errors in hospitals statistics to create a National Alert Network (NAN) that broadens the reach of those alerts. The NAN warns healthcare providers through several medication errors in hospitals statistics 2014 national distribution channels of the risk for medication errors that have recently caused serious harm or death. The alerts are based on information submitted to the ISMP National Medication Error Reporting Program. National
Medication Errors In Hospitals Articles
Alert Network (NAN) Alerts 2016 September 2016 Observe for possible fluid leakage when preparing parenteral syringes 2015 June 2015 Move toward full use of metric dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL March 2015 Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection 2014 February 2014 Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation
Medication Errors Articles
2013 June 2013 Important change with heparin labels April 2013 Confusion regarding the generic name of the HER2-targeted drug KADCYLA (ado-trastuzumab emtansine) January 2013 Remove “glacial” acetic acid now! 2012 April 2012 Proper disposal of fentaNYL patches is critical to prevent accidental exposure March 2012 Potential for wrong route errors with Exparel (bupivacaine liposome injectable suspension) 2011 June 2011 Risk of potentially fatal overdose with colistimethate 2010 June 2010 EPINEPHrine pre-filled syringe shortage 2009 August 2009 Errors lead to fatal hyponatremia in two healthy children ISMP Hazard alerts 2009 October 2009 Tamiflu oral suspension shortage contributing to dosing errors 2004 October 2004 ISMP urges immediate replacement of Brethine ampuls with vials! 2003 May 2003 Confusion between tetanusdiphtheria toxoid (Td) and tuberculin purified protein derivative (PPD) led to unnecessary treatment. 2002 December 2002 Methotrexate overdose due to inadvertent administration daily instead of weekly November 2002 The availability of certain newer needleless IV system connection ports makes it possible to inject fluid into the valve of these connectors with an oral syringe February 2002 Recurring confusion between tincture of opium and paregoric 2001 August 2001 Asphyxiation possible with syringe tip caps. Do not provide hypodermic syringes to parents for administering oral liquids to chil
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Me Forgot Password? Login or Sign up for a Free Account My Topics of Interest My CME My Profile Sign Out Home Topics Issues WebM&M Cases Perspectives Primers Submit Case CME / CEU https://psnet.ahrq.gov/primers/primer/23/medication-errors Training Catalog Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial Team Technical Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Patient Safety http://www.nccmerp.org/about-medication-errors Primer Last Updated: March 2015 Medication Errors Topics Resource Type Patient Safety Primers Safety Target Medication Errors/Preventable Adverse Drug Events Look-Alike, Sound-Alike Drugs More Share Facebook Twitter Linkedin Email Print Background medication error and definitions Prescription medication use is widespread, complex, and increasingly risky. Clinicians have access to an armamentarium of more than 10,000 prescription medications, and nearly one-third of adults in the United States take 5 or more medications. Advances in clinical therapeutics have undoubtedly resulted in major improvements in health for patients with many diseases, but these benefits have also been accompanied by increased medication errors in risks. An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication, and ADEs account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. ADEs affect nearly 5% of hospitalized patients, making them one of the most common types of inpatient errors; ambulatory patients may experience ADEs at even higher rates. Transitions in care are also a well-documented source of preventable harm related to medications. As with the more general term adverse event, the occurrence of an ADE does not necessarily indicate an error or poor quality care. A medication error refers to an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. Preventable adverse drug events result from a medication error that reaches the patient and causes any degree of harm. It is generally estimated that about half of ADEs are preventable. Medication errors that do not cause any harm—either because they are intercepted before reaching the patient, or by luck—are often called potential AD
Drug Event AlgorithmRecommendations / StatementsFor Consumers About Medication Errors What is a Medication Error? The Council defines a "medication error" as follows: "A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use." The Council urges medication errors researchers, software developers, and institutions to use this standard definition to identify errors. NAN Alert The National Alert Network (NAN) publishes the alerts from the National Medication Errors Reporting Program. NAN encourages the sharing and reporting of medication errors, so that lessons learned can be used to increase the safety of the medication use system. September 15, 2016 Observe for possible fluid leakage when preparing parenteral syringes Subscribe Archive Popular links Definition Taxonomy Dangerous Abbreviations Upcoming Meetings There is no meeting avaiable. Previous Meetings Report Medication ErrorsISMP Medication Errors Reporting Program (MERP) Go U.S. Food and Drug Administration's MedWatch Reporting Program © 2016 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. *Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied. This copyright statement will change to the new year after the 1st of every year.