Order Scanning Systems may Simultaneously Pull Multiple Pages;Through the Scanner,Leading to Drug Omissions;Dangerous Name Pair;Be Clear When Teaching People to Use Their Inhalers;Inaccurate Dosing If Insulin Withdrawn from a Pen Cartridge

Abstract

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 Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. 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 directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at [e-mail]. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.