Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs.
ISMP Medication Safety Alert! Acute care edition. July 29, 2021;26(15);1-5.
Tubing misconnections have been associated with medication administration errors, and yet, design strategies to minimize these mistakes are only beginning to be uniformly implemented. This article shares the story of a contrast media administration error associated with communication and handoff errors. The piece recommends focusing on universal design standards to improve administration along with clinical steps to mitigate the potential for this type of error.