Medication Errors Reporting Program Research Articles

Multifactorial Causes of Tacrolimus Errors: Confusion With Strength/Formulation, Look-Alike Names, Preparation Errors, and More Ensuring Safety of Recipes for Drug Compounding Please, no more teaspoon dosing.

A recent string of errors associated with tacrolimus, an immunosuppressant used primarily to prevent rejection in transplant recipients, prompted ISMP to review the literature and analyze related events reported to the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) and the ISMP National Medication Errors Reporting Program (MERP). We found that tacrolimus has been involved in many reported errors during the past decade that have been caused by a wide variety of factors, the most common of which are described below.

IV Push Medication Administration: Making Safe Choices; Choosing Best Practice

It has been estimated that more than 90% of hospitalized patients receive some form of intravenous (IV) therapy. 1 Baranowski L Presidential address: take ownership. J Intraven Nurs. 1995; 18: 162-164 PubMed Google Scholar , 2 Corrigan A Infusion nursing as a specialty. in: Alexander M Corrigan A Gorski L Hankins J Perucca R Infusion Nursing: An Evidence-based Approach. 3rd ed. Saunders Elsevier, St Louis, MO2010 Google Scholar Errors involving the use of IV medications are more common than once recognized and occur in all phases of the medication use process. These errors can be particularly dangerous, depending on the drug’s properties and the complexity of its therapeutic action. Although IV push medications are clinically advantageous because of their immediate therapeutic effect, they are also challenging because of an immediate bioavailability of the administered drug, a narrow therapeutic dose range, and limitations in reversing systemic effects, all of which can contribute to harm. 3 American Society of Health-System Pharmacists Summit proceedings. Am J Health Syst Pharm. 2008; 65: 2367-2379 Google Scholar , 4 Hicks R Becker S An overview of intravenous-related medication administration errors as reported to MEDMARX®, a national medication error-reporting program. J Infus Nurs. 2006; 29: 20-27 Crossref PubMed Scopus (66) Google Scholar The significant risk for patient injury and death related to IV medication errors is well known. 3 American Society of Health-System Pharmacists Summit proceedings. Am J Health Syst Pharm. 2008; 65: 2367-2379 Google Scholar , 4 Hicks R Becker S An overview of intravenous-related medication administration errors as reported to MEDMARX®, a national medication error-reporting program. J Infus Nurs. 2006; 29: 20-27 Crossref PubMed Scopus (66) Google Scholar , 5 Aspden P Wolcott JA Bootman JL Cronenwett LR Committee on Identifying and Preventing Medication Errors, Board on Health Care Services, Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. National Academy Press, Washington, DC2007 Google Scholar , 6 Flynn EA Barker KN Research on errors in dispensing and medication administration. in: Cohen MR Medication Errors. 2nd ed. American Pharmacists Association, Washington, DC2007: 15-41 Google Scholar , 7 Kaushal R Bates DW Landrigan C et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285: 2114-2120 Crossref PubMed Scopus (1379) Google Scholar , 8 Ross LM Wallace J Paton JY Medication errors in paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000; 83: 492-497 Crossref PubMed Scopus (262) Google Scholar , 9 Institute for Safe Medication Practices Institute for Safe Medication Practices National Medication Errors Reporting Program Database. Institute for Safe Medication Practices, Horsham, PA2015 Google Scholar The Institute for Safe Medication Practices (ISMP) has received and published numerous IV push–related error reports involving patient injury obtained through its National Medication Errors Reporting Program. 9 Institute for Safe Medication Practices Institute for Safe Medication Practices National Medication Errors Reporting Program Database. Institute for Safe Medication Practices, Horsham, PA2015 Google Scholar Susan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP 1ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention.1ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.) Michelle Mandrack is Director of Consulting Services, Institute for Safe Medication Practices, Horsham, PA.

The Institute for Safe Medication Practices and Poison Control Centers: Collaborating to Prevent Medication Errors and Unintentional Poisonings.

This article provides an overview on the Institute for Safe Medication Practices (ISMP), the only independent nonprofit organization in the USA devoted to the prevention of medication errors. ISMP developed the national Medication Errors Reporting Program (MERP) and investigates and analyzes errors in order to formulate recommendations to prevent further occurrences. ISMP works closely with the US Food and Drug Administration (FDA), drug manufacturers, professional organizations, and others to promote changes in package design, practice standards, and healthcare practitioner and consumer education. By collaborating with ISMP to share and disseminate information, Poison Control centers, emergency departments, and toxicologists can help decrease unintentional and accidental poisonings.

Risk of Cutting Certain Medication Patches; Warfarin by Generic Name; Why Doctors Must Include Medication Purpose on Prescriptions; Carac-Kuric Mix-Ups

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Misprogramming Patient-Controlled Analgesia Concentration Leads to Dosing Errors; Communicate Alteplase Dose and Indication; Do Not Use Empty Prelabeled Syringes/Bowls

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Controlled Drug Symbol C-IV Mistaken as IV; Fatal Medication Errors in the Home; Ambulatory E-Prescribing Requires Patient's Check; EPINEPHrine-ePHEDrine Mix-Ups

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Epidural-Intravenous Route Mix-Ups: Reducing the Risk for Deadly Errors; Discontinued Drug Leads to Error

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Identify Home Medications Restricted Character Space and Truncated Drug Listings are a Set-Up for Medication Errors “can't Tell a Book by its Cover” Rings True for Medications Child Dies from Misuse of Fentanyl Patch

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Avoid Confusion with Torisel Dose Preparation; Remove Vials from Cartons; Sumatriptan Confused with Sitagliptin; Misdispensing of Purinethol Instead of Propylthiouracil: A Preventable Disaster

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the United States Pharmacopeia (USP) Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Medication Errors Associated with Cerebyx; Consumer Safety with Creams and Ointments; Caution Regarding Color-Coded Eye Medications; Strength Misread as Total Dose

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Cross Contamination with Insulin Pens; Look-Alike Vials; Kids and Medication Patches; New Look-Alike Name Pair; Preventing Dosing Errors with Methotrexate Injection

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP tollfree, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Keeping Patients Safe from Iatrogenic Methadone Overdoses Final Curtain for IV Colchicine Overdoses

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Persistence Saves Patient's Life; Do Not Use Epidural Tubing for an Intravenous Solution; Topical Antiseptic Given Orally; Refrigerator Monitoring

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

One Tablet or One Bottle? Avoiding Mix-Ups between Sterile Water and Sodium Chloride Bags a Chain is Only as Strong as its Weakest Link

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Errors with Injectable Medications: Unlabeled Syringes are Surprisingly Common; Unintended Consequences of High-Alert Stickers; Easily Misread Abbreviations

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP tollfree, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Preventing Mix-Ups between Various Formulations of Amphotericin B; Cardiac Catheterization Lab Error; Say Again?; Colchicine Deaths

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). If you have encountered medication errors and would like to report them, you may call USP tollfree, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or United States Pharmacopeia (USP) ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Lack of Standard Dosing Methods Contribute to IV Errors Talc Misadministered IV

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Failure to Cap IV Tubing and Disinfect IV Ports Places Patients at Risk for Infections; Unintended Consequences of CPOE; Numerous Problematic Name Pairs Relegated to History

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Reports published by ISMP are anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Ongoing Incidents Involving Fentanyl Patches are Alarming!; Insulin CONCENTRATE U-500; WHO: Dilute Vincristine in a Minibag

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

IV Tubing Misconnected to Tracheostomy Cuff; Unidentifiable Patches; A Risk that should Not be Tolerated

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program (MERP), which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported through the ISMP ( www.ismp.org ) or USP ( www.usp.org ) Web sites or communicated directly to ISMP by calling 800-FAIL-SAFE or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.