Acute Care Volume 24, Issue 1

Medication Safety Alert! January 17, 2019

In this week's issue:

Featured article

Problem: National news recently exposed details about a 2017 fatal medication error that happened at a large, prestigious hospital after the Centers for Medicare & Medicaid Services (CMS) briefly placed its Medicare reimbursement status in jeopardy. The hospital’s status was quickly restored following submission of a plan of correction to CMS. Upon ISMP’s awareness of the event, it became imperative to share the lessons learned from the fatal event so other healthcare providers can avoid a similar tragedy.

The details of the error that follow are from a CMS report. As the story unfolds, we...

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