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Highlighted Articles


7/31/2014 Safety requires a state of mindfulness (Part 1)
7/17/2014 With oral chemotherapy, we simply must do better!
7/3/2014 Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications
6/19/2014 Some IV medications are diluted unnecessarily in patient care areas, creating undue risk
6/5/2014 Misidentification of alphanumeric symbols
5/22/2014 Administering just the diluent or one of two vaccine components leaves patients unprotected
5/8/2014 QuarterWatch ™ Drug hypersensitivity reactions  Allergic reactions second most frequently reported serious event
4/24/2014 Part II: Disrespectful behaviors Their impact, why they arise and persist, and how to address them
4/10/2014 Take a tour of ISMP’s ConsumerMedSafety.org website: Provide your patients with a link to the site
3/27/2014 Still outside the bull’s eye: 2014-2015 Targeted Medication Safety Best Practices (Baseline survey results)
3/13/2014 Use caution when “alternatives” are proposed with ambulatory e-Rx systems
3/13/2014 Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors
8/23/2012 Generic methylergonovine and Engerix-B mix-ups due to look-alike vials
2/27/2014 ISMP Canada identifies themes associated with fatal medication events in the home
2/13/2014 How FDA can help reduce dabigatran (PRADAXA) bleeding risks
2/13/2014 Survey links PN component shortages to adverse outcomes
1/30/2014 Regarding the current IV solution shortage affecting US hospitals
1/30/2014 A mislabeling event with batched drugs: The unintended consequences of practice changes
1/16/2014 QuarterWatch (Special Report): Adverse drug events in children less than 18 years old
12/12/2013 The 16th Annual CHEERS Awards: Feel the Rhythm of Change in Medication Safety
11/28/2013 First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP)
11/14/2013 Understanding and managing IV container overfill
10/31/2013 As U-500 insulin safety concerns mount, it’s time to rethink safe use of strengths above U-100
10/17/2013 QuarterWatch ™ 2012 Annual Report Anticoagulants, anti-TNF drugs, fentaNYL patches, and alendronate
10/3/2013 Unresolved disrespectful behavior in healthcare Practitioners speak up (again)-Part I
9/19/2013 Small effort, big payoff... Automated maximum dose alerts with hard stops
9/5/2013 Death and neurological devastation from intrathecal vinca alkaloids: Prepared in syringes = 120; Prepared in minibags = 0
8/22/2013 Developing productive partnerships with technology and device vendors to improve staff training
8/8/2013 FentaNYL patch fatalities linked to “bystander apathy” We ALL have a role in prevention!
7/25/2013 FROM THE HOSPITAL to LONG-TERM CARE:  PROTECTING VULNERABLE PATIENTS DURING HANDOFF
7/11/2013 In utero medication administration to fetus presents unique safety challenges
6/27/2013 Disrespectful behavior in healthcare... Have we made any progress in the last decade?
6/13/2013 Independent Double Checks: Undervalued and Misused: Selective use of this strategy can play an important role in medication safety
5/30/2013 Fatal PCA adverse events continue to happen… Better patient monitoring is essential to prevent harm
5/16/2013 Administering a saline flush “site unseen” can lead to a wrong route error
5/2/2013 Survey results show medication safety information provided by ISMP is valued and acted upon by US hospitals
4/18/2013 QuarterWatch (April 2013 issue) Perspective on GLP-1 agents for diabetes
4/4/2013 Your high-alert medication list—Relatively useless without associated risk-reduction strategies
3/21/2013 Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit
3/7/2013 Survey results: Community liaison programs to decrease hospital readmissions
2/21/2013 A clinical reminder about the safe use of insulin vials
2/7/2013 Ongoing concern about insulin pen reuse shows hospitals need to consider transitioning away from them
1/24/2013 Survey results: How hospitals are managing the preparation and purchase of high-risk compounded sterile preparations (CSPs)
1/10/2013 QuarterWatch™ (2012—Quarter 2) Signals for finasteride, methylphenidate patches, and anticoagulants
12/13/2012 The 15th Annual ISMP Cheers Awards: Meet this year’s true gems in medication safety
11/29/2012 Side tracks on the safety express. Interruptions lead to errors and unfinished… Wait, what was I doing?
11/15/2012 Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community
11/1/2012 Moving forward for safer sterile compounding
10/18/2012 Sterile compounding tragedy is a symptom of a broken system on many levels
10/4/2012 QuarterWatch™ (2012—Quarter 1) Signals for DULoxetine, pioglitazone, aliskiren, and rivaroxaban
9/20/2012 Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections
9/6/2012 Prescription drug time guarantees and their impact on patient safety in community pharmacies
8/23/2012 Avoiding inadvertent IV injection of oral liquids
8/9/2012 ISMP survey reveals user issues with Carpuject prefilled syringes
7/26/2012 Raising the index of suspicion: Red flags that represent credible threats to patient safety
7/12/2012 Just Culture and its critical link to patient safety (Part II)
6/28/2012 Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors
6/14/2012 Dr. Leape and colleagues present a compelling call to action to establish a culture of respect
5/31/2012 QuarterWatch™2011 Annual Report An estimated 2 to 4 million drug-induced serious injuries in 2011
5/17/2012 Just Culture and its critical link to patient safety (Part I)
5/3/2012 Cheers honoree’s acceptance speech creates pause for reflection
4/19/2012 A shortage of everything except errors: Harm associated with drug shortages
4/5/2012 QuarterWatch™ (second quarter 2011) Signals identified for fingolimod and inFLIXimab
3/22/2012 Results of our survey on drug storage, stability, compatibility, and beyond use dating
3/8/2012 Good intention, uncertain outcome... Our take on physician dispensing in offices and clinics
2/23/2012 Smart pump custom concentrations without hard “low concentration” alerts
2/9/2012 Results of ISMP survey on High-Alert Medications: Differences between nursing, pharmacy, and risk/quality/safety perspectives
1/26/2012 Does the CMS?standard to store medications according to manufacturer’s directions impact drug shortages and increase waste?
1/26/2012 Don’t let the “tobacco stain” on pharmacies that sell cigarettes be a barrier to advanced pharmacy practice (Report to Surgeon General calls for recognition and compensation of pharmacists)
1/12/2012 QuarterWatch™ (First Quarter 2011) Signals for dabigatran and metoclopramide
12/15/2011 14th Annual ISMP CHEERS Awards... Winners honored in New Orleans amid All that Jazz…
12/1/2011 Look out for Lugol’s... Error-prevention strategies for this strong iodine solution
11/17/2011 Conservative prescribing needed to improve medication safety
11/3/2011 Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children
10/20/2011 FDA Advise-ERR: FDA approves HYDROmorphone labeling revisions to reduce medication errors
10/6/2011 QuarterWatch™ 2010 (Quarter 4 and annual summary) Signals for two newly approved drugs: dabigatran and dalfampridine
9/22/2011 Durasal-Durezol mix-up illustrates how dangerous product problems persist long after recognition
9/8/2011 Telling true stories is an ISMP hallmark Here’s why you should tell stories, too…
8/25/2011 Gray market, black heart: Pharmaceutical gray market finds a disturbing niche during the drug shortage crisis
08/11/2011 Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment
07/28/2011 Oral solid medication appearance should play a greater role in medication error prevention
07/14/2011 Too many abandon the "second victims" of medical errors
06/30/2011 Scanner beep only means the barcode has been scanned
06/16/2011 Parents can detect, contribute to, or be affected by critical events during a child's hospitalization
06/02/2011 Safe practices in pharmacy sterile compounding areas
05/19/2011 QuarterWatchT: 2010 (Quarter 3)
New signals for liraglutide, QUEtiapine, and varenicline
05/05/2011 Multiple latent failures align to allow a serious drug interaction to harm a patient
04/21/2011 Another tragic parenteral nutrition compounding error
04/07/2011 TPN-related deaths call for FDA guidance and pharmacy board oversight of USP Chapter <797>
03/24/2011 Diabetes in Control.com-A website for medical professionals
03/10/2011 Oops, sorry, wrong patient!
A patient verification process is needed everywhere, not just at the bedside
02/24/2011 That's the way we do things around here!
Your ACTIONS speak louder than words when it comes to patient safety
02/10/2011 Preventing medication errors during codes
01/27/2011 ISMP QuarterWatchT Report (2010 Quarter 2) Adverse drug event signals warrant action
01/13/2011 Guidelines for timely medication administration
Response to the CMS "30-minute rule"
12/16/2010 The 13th Annual CHEERS Awards: And the Winners Are.
12/02/2010 Perilous infection control practices with needles, syringes, and vials suggest stepped-up monitoring is needed
11/18/2010 ISMP updates its list of drug name pairs with TALL man letters
11/04/2010 ISMP QuarterWatchT Report (2010 Quarter 1)
Signals for acetaminophen, dronedarone, and botulinum toxins
10/21/2010 Dakin's solution accidentally given IV
10/07/2010 Weathering the storm: Managing the drug shortage crisis
09/23/2010 Special Issue
Drug shortages: National survey reveals high level of frustration, low level of safety
09/09/2010 CMS 30-minute rule for drug administration needs revision
08/26/2010 Electronic prescribing vulnerabilities: Height and weight mix-up leads to dosing error
08/12/2010 Affirmative warnings (do this) may be better understood than negative warnings (do not do that)
08/12/2010 Generic enoxaparin syringe issue
07/29/2010 Drug shortages threaten patient safety
07/15/2010 Preventing catheter/tubing misconnections: Much needed help is on the way
07/01/2010 DTaP-Tdap mix-ups now affecting hundreds of patients
06/17/2010 ISMP QuarterWatch (Quarter 4 and 2009 totals) - Reported patient deaths increased by 14% in 2009
06/03/2010 Failure to set a volume limit for a magnesium bolus dose leads to harm
05/20/2010 Safe practice with the potent once daily opioid Exalgo
05/06/2010 Preventing errors when administering drugs via an enteral feeding tube
04/22/2010 Building Patient Safety Skills
Common pitfalls when conducting a root cause analysis
04/08/2010 Latest heparin fatality speaks loudly-What have you done to stop the bleeding?
03/11/2010 ISMP develops guidelines for standard order sets
03/25/2010 California Department of Public Health Medication Error Reduction Plan
03/11/2010 ISMP develops guidelines for standard order sets
02/25/2010 ISMP QuarterWatchT (2009 Quarters 1, 2, and 3)
Increased reports of ADEs with Zicam cold products, rosiglitazone, QUEtiapine, testosterone gel, and recalled products
02/11/2010 FDA Advise-ERR: A new look for Morphine Sulfate 100 mg per 5 mL (20 mg/mL) Oral Solution
01/28/2010 Baclofen programming error with SynchroMed II pump
Facility not made aware of company's software updates
01/14/2010 Survey shows recession has weakened patient safety net
12/17/2009 Santa checks his list twice. Shouldn't we?
12/03/2009 Eric Cropp weighs in on the error that sent him to prison
11/19/2009 Shakespeare was on target-don't be a borrower or lender
11/05/2009 Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions
10/22/2009 Oral syringes: A crucial and economical risk-reduction strategy that has not been fully utilized
10/08/2009 ISMP QuarterWatchT
Serious adverse drug event reports increase last quarter, 2008
09/24/2009 ISMP survey helps define near miss and close call
09/10/2009 How has the current economy affected patient safety?
08/27/2009 Ohio government plays Whack-a-Mole with pharmacist
08/13/2009 Plain D5W or hypotonic saline solutions post-op could result in acute hyponatremia and death in healthy children
07/30/2009 Will color-tinted IV tubing help?
07/16/2009 Process for handling elastomeric pain relief balls (ON-Q PainBuster and others) requires safety improvements
07/02/2009 Misidentification of alphanumeric symbols in both handwritten and computer-generated information
06/18/2009 Intrathecal injection warrants mask worn by clinician during procedure
06/04/2009 Icons and symbols on IV related products: Global industry must reflect on the safety aspects.
05/21/2009 Survey on LASA drug name pairs:
Who knows what's on your list and the best ways to prevent mix-ups?
05/07/2009 QuarterWatch (3rd quarter 2008)
Safety concerns with generics, Chantix aggressive behavior, and more
04/23/2009 Failed check system for chemotherapy leads to pharmacist's no contest plea for involuntary manslaughter
04/09/2009 Shared MDIs: Can cross-contamination be avoided?
03/26/2009 Fatal outcome after inadvertent injection of topical EPINEPHrine
03/12/2009 Beware of basal opioid infusions with PCA therapy
02/26/2009 Inattentional blindness: What captures your attention?
02/12/2009 Follow ISMP Guidelines to safeguard the design and use of automated dispensing cabinets (ADCs)
01/29/2009 Revatio=sildenafil=Viagra
01/15/2009 ISMP QuarterWatchT (2nd quarter 2008)
12/18/2008 Color-coded syringes for anesthesia drugs: use with care
12/04/2008 Safe practice environment chapter proposed by USP
11/20/2008 Actively caring for safety: Overcoming bystander apathy
11/06/2008 Using external errors to signal a clear and present danger
10/23/2008 ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events
10/09/2008 Collaboration focused on priority issues promotes safety
09/25/2008 Report and spread information about software risks
09/11/2008 Don't underestimate the impact of change on risk potential
08/28/2008 Misprogramming PCA concentration leads to dosing errors
08/14/2008 Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning
07/31/2008 Use of tall man letters is gaining wide acceptance
07/17/2008 Heparin errors continue despite prior, high-profile, fatal events
07/03/2008 Epidural-IV route mix-ups: Reducing the risk of deadly errors
06/19/2008 FDA Advise-ERR: Prevent dangerous drug-device interaction causing falsely elevated glucose levels
06/05/2008 Benefits and risks of including patients on RCA teams
05/22/2008 Managing visits from pharmaceutical sales representatives
05/08/2008 Considering insulin pens for routine hospital use? Consider this...
04/24/2008 Some red rules shouldn't rule in hospitals
04/10/2008 FDA Advise-ERR: Medication errors associated with Cerebyx
03/27/2008 There's more to the 60 Minutes story on heparin errors
03/13/2008 Resolving human conflicts when questions about the safety of medical orders arise
02/28/2008 USA Today news series: Clarifying the issues and embracing community pharmacy safety
02/14/2008 Keeping patients safe from iatrogenic methadone overdoses
01/31/2008 Fatal overdose uncovers need to rethink where pediatric IV medications are dispensed and administered
01/17/2008 ADC survey shows some improvements, but unnecessary risks still exist
12/13/2007 Celebrating 10 years of ISMP CHEERS awards
11/29/2007 Another heparin error: Learning from mistakes so we don't repeat them
11/15/2007 Errors with injectable medications: Unlabeled syringes are surprisingly common!
11/01/2007 Product-related issues make error potential enormous with investigational drugs
10/18/2007 Error-prone conditions that lead to student-nurse related errors.
10/04/2007 Potassium may no longer be stocked on patient care units, but serious threats still exist!
09/20/2007 Fluorouracil error ends tragically, but application of lessons learned will save lives
09/06/2007 Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg
08/23/2007 Lack of standard dosing methods contributes to IV errors
08/09/2007 Progress with preventing name confusion errors
07/26/2007 Failure to cap IV tubing and disinfect IV ports place patients at risk for infections
07/12/2007 Requirement #1-Patch should stick to the patient!
06/28/2007 Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!
06/14/2007 Infusion free-flow apparently still a risk
05/31/2007 Remote CPOE error-a situation that's more than remotely possible
05/17/2007 ISMP 2007 survey on HIGH-ALERT medications
Differences between nursing and pharmacy perspectives still prevalent
05/03/2007 Action needed to prevent dangerous heparin-insulin confusion
04/19/2007 Smart pumps are not smart on their own
04/05/2007 Failure to clearly link TYLENOL products to acetaminophen poses serious threat to safety
03/22/2007 If safety is your yardstick, measuring culture from the top down must be a priority
03/08/2007 Criminal prosecution of human error will likely have dangerous long-term consequences
02/22/2007 HIGH ALERT Medication Feature
Reducing patient harm from opiates
02/08/2007 Heed this warning! Don't miss important computer alerts
01/25/2007 The five rights: A destination without a map
01/11/2007 High-Alert Medication Feature: Anticoagulant safety takes center stage in 2007
12/14/2006 The 9th Annual ISMP CHEERS Awards: And The Winners Are...
11/30/2006 PEN injectors: Technology is not without imPENding risks
11/16/2006 Pharmaceutical industry medical device companies:
Part of the solution?
11/02/2006 Promethazine conundrum: IV can hurt more than IM injection!
Survey spurs interest in renewing efforts to prevent serious tissue damage
10/19/2006 "And the 'EYES' have it": Eardrops, that is...
10/05/2006 Harmful errors: How will your facility respond?
09/21/2006 Our long journey towards a safety-minded Just Culture
Part II: Where we're going
09/07/2006 Our long journey towards a safety-minded Just Culture
Part I: Where we’ve been
08/24/2006 Your attention please. Designing effective warnings
08/10/2006 Action needed to prevent serious tissue injury with IV promethazine
07/27/2006 ISMP comments on IOM report, Preventing Medication Errors
07/13/2006 Practitioners agree on medication reconciliation value, but frustration and difficulties abound
06/29/2006 Vincristine therapy: days "4-11" misunderstood as days 4 through 11
06/15/2006 Preventing accidental IV infusion of breast milk in neonates
06/01/2006 Rapid response team activation by patients can mitigate errors
05/18/2006 Tablet splitting: Do it only if you "half" to, and then do it safely
05/04/2006 Pump design flaws demonstrate need for practitioner involvement in FMEA
04/20/2006 Original document needed to scan orders to pharmacy
04/06/2006 IV potassium given epidurally: getting to the "route" of the problem
03/23/2006 Safety requires a state of "mindfulness" (Part II)
03/09/2006 Safety requires a state of "mindfulness" (Part I)
02/23/2006 IV vincristine survey shows safety improvements needed
02/09/2006 Pump up the volume - Tips for increasing error reporting
01/26/2006 What does your patient safety brochure really say about safety?
01/12/2006 Infusion pump double key bounce and double keying errors
12/15/2005 The 8th Annual ISMP CHEERS Awards: And the winners are...
12/01/2005 Fatal misadministration of IV vincristine
11/17/2005 Mail service and community pharmacies must work in tandem
11/03/2005 Propofol sedation: Who should administer?
10/20/2005 Preventing magnesium toxicity in obstetrics
10/06/2005 Unfortunately, this time it wasn't the equipment
09/22/2005 Paralyzed by mistakes. Preventing errors with neuromuscular blocking agents
09/08/2005 Be aware of false glucose results with point–of-care testing
08/25/2005 Safety still compromised by computer weaknesses
Comparing 1999 and 2005 pharmacy computer field test results
08/11/2005 New fentanyl warnings: more needed to protect patients
07/28/2005 High-reliability organizations (HROs):
What they know that we don't (Part II)
07/14/2005 High-reliability organizations (HROs):
What they know that we don't (Part I)
06/30/2005 Two steps forward and one step back for patient safety?
Two groups focus on improved outcomes, another on Rx "vending" machines
06/16/2005 Symlin insulin adjunct presents safety issues
06/02/2005 An exhausted workforce increases the risk of errors
05/19/2005 Practitioners anticipate punitive action from licensing bodies
05/05/2005 End the ice age-Is glacial acetic acid really needed?
04/21/2005 Building a case for medication reconciliation
04/07/2005 Patient's watchful eye and Internet lead to pump tampering
03/24/2005 Medication orders: Don't put me on hold
Joint Commission and use of the Broselow tape
Sterile cockpit
03/10/2005 Measuring up to medication safety
02/24/2005 Welcome to the State Board of (Nursing, Pharmacy, Medicine) Inquisitions
02/10/2005 The truth about hospital formularies
Survey shows many myths still exist 15 years later
   
01/27/2005 New dangers in the drug reimportation process: Will we know what our patients are taking?
01/13/2005 Looking forward: Make "pro-change" your New Year's Resolution
12/16/2004 Fatal gas line mix-up: How to avoid making this "gastly" mistake
2004 ISMP CHEERS for medication safety: Celebrating excellence
12/02/2004 Loud wake-up call: Unlabeled containers lead to patient's death
11/18/2004 The truth about hospital formularies: We've come a long way, or have we?
11/04/2004 FDA and the pharmaceutical industry must be more responsive for a safer healthcare system
10/21/2004 Hazard Alert!
ISMP urges immediate replacement of Brethine ampuls with vials!
10/07/2004

Reducing "at-risk behaviors"
Part II of Patient safety should NOT be a priority in healthcare!

09/23/2004

Patient safety should NOT be a priority in healthcare!
Part I: Why we engage in "at-risk behaviors"

09/09/2004

Inflated risk: Inadvertent drug injections into inflation port
Potential confusion with AMARYL (glimepiride) and REMINYL (galantamine)

08/26/2004 Root causes: A roadmap to action
08/12/2004 Hospital and medical staff leadership is key to compliance with JC dangerous abbreviation list
07/29/2004 Misprogram a PCA pump? It's easy!
07/15/2004 Lowdown on lomustine: We’d hate CeeNU make this mistake
07/01/2004 An omnipresent risk of morphine-hydromorphone mix-ups
06/17/2004 Problems persist with life-threatening tubing misconnections
06/03/2004 Oops, sorry, wrong patient!Applying the JC “two-identifier” rule beyond the patient’s room
05/20/2004 The high cost of medications: A bitter pill to swallow
05/06/2004 Bicillin products: Syringe enhancements may help to prevent IV administration

04/22/2004

Improvised drug delivery: A cause for concern
Hazard warning with BRETHINE and METHERGINE.

04/08/2004

Burns in MRI patients wearing transdermal patches
Confusion caused by several different products with DULCOLAX brand name.

03/25/2004

Intimidation: Practitioners speak up about this unresolved problem (Part II)

03/11/2004

Intimidation: Practitioners speak up about this unresolved problem (Part I)

02/26/2004

Broselow tape: Measuring the changes from 1998 to today

02/12/2004

Safety issues with adding lidocaine to IV potassium infusions

01/29/2004

Evidence-based medicine doesn’t preclude common sense

01/15/2004

Template for disaster? Fatal injection into wrong port of implanted infusion pump

12/18/2003

2003 CHEERS for medication safety: Celebrating excellence
ISMP's list of high-alert medications

11/27/2003

Intrathecal injection of ionic contrast media may be fatal

11/13/2003

A spectrum of problems with using color

10/30/2003

Double-checks for endogenous and exogenous errors

10/16/2003

Survey on high-alert medications
Differences between nursing and pharmacy perspectives revealed

10/02/2003

Helping to remove the barriers to patient education

09/18/2003

How sterile water bags show up on nursing units

09/04/2003

Cultural diversity and medication safety

08/21/2003

Is an antithyroid or antimetabolite needed?

08/07/2003

How are you preventing acetaminophen overdoses?

07/24/2003

Part II - How to prevent errors - Safety issues with patient-controlled analgesia

07/10/2003

Safety issues with patient-controlled analgesia Part I - How errors occur

06/26/2003

New data monitoring technology offers real-time reporting of impending adverse events

06/12/2003

Blood pressure monitor tubing may connect to IV ports

05/29/2003

Mind your “Medrols

05/15/2003

How fast is too fast for IV push medications?

05/01/2003

Nix the quick fix: Drug protocols require groundwork

04/17/2003

"Looks" like a problem: ephedrine - epinephrine

04/03/2003

U cnt abbrv “Patient Safety”

03/20/2003

Last week was National Patient Safety Week – and what a week it was!

03/06/2003

The virtues of independent double checks – they really are worth your time!

02/20/2003

It’s time for standards to improve safety with electronic communication of medication orders

02/06/2003

The reports are in…or are they? Awareness of medication error reporting programs needs a boost

01/23/2003

Water, water, everywhere, but please don't give IV

01/09/2003

Success with New Year's resolutions requires more than personal resolve

12/18/2002

"Cheers" for medication safety: Celebrating those who made a difference in 2002

11/24/2002

Watch out for this turkey - Complacency

11/13/2002

Face it! Intimidation presents serious safety issues

10/30/2002

Tricks but no treats: Illusions and medication errors

10/16/2002

It doesn't pay to play the percentages

10/03/2002

Benzocaine-containing topical sprays and methemoglobinemia

09/18/2002

Bad "marks" for order communication

09/04/2002

Involving non-clinical departments in patient safety discussions can reduce the risk of serious errors

08/21/2002

The road less traveled

08/07/2002

Accidental childhood acetaminophen overdoses illustrate our responsibility to educate parents

07/24/2002

Pain scales don't weigh every risk

07/10/2002
06/26/2002

Pharmacy interventions - Part I and II from ISMP survey

06/12/2002

What's in a name? Ways to prevent dispensing errors linked to name confusion
A medication error trifecta!

05/29/2002

More on avoiding opiate toxicity with PCA by proxy

05/15/2002

Atrocious labeling of plastic ampuls needs action now by FDA and manufacturers

05/01/2002

Annenberg Conference sends a patient's message: "Nothing about me without me"

04/17/2002

Remote order entry: Innovative practice to reduce distractions and offer 24-hour pharmacy service

04/03/2002

Beware of erroneous daily oral methotrexate dosing

03/20/2002

Practitioner access to the Internet: A necessity in a modern hospital

03/06/2002

ISMP survey shows drug companies providing fewer unit dose packaged medications

02/20/2002

Eliminating dangerous abbreviations and dose expressions in the print and electronic world

02/07/2002

"Smart" infusion pumps join CPOE and bar coding as important ways to prevent medication errors

01/23/2002

Shortsighted JC standard lacks understanding of pharmacist's role in prospective order review

01/09/2002

Messages in our mailbox

12/12/2001

The year 2001 at a glance: ISMP's medication safety "Cheers"

11/28/2001

IV connection to tracheostomy cuff inflation port reflects larger problem

11/14/2001

Supervision often a weak link in error prevention

10/31/2001

To promote understanding, assume every patient has a health literacy problem

10/17/2001

Failure Mode and Effects Analysis can help guide error prevention efforts

10/03/2001

Systems thinking: Tap into staff creativity to unleash innovation

09/19/2001

ISMP survey on perceptions of a nonpunitive culture produces some surprising results

08/08/2001

It's time for a new model of accountability

07/25/2001

The supermarkets do it - so why can't we raise the "bar" in health care?

07/11/2001

Patient safety is all about taking that extra step

06/28/2001

Insights into people will improve our safety systems.

06/13/2001

Medication error or professional judgement?

05/30/2001

New official interpretation of JC standard bans open access to pharmacy after hours

05/02/2001

Please Don't Sleep Through this Wake-Up Call
Includes ISMP's table of dangerous medical abbrevations

04/18/2001

Lessons Lost by the Global Pharmaceutical Industry

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