"DO NOT CRUSH" List
Oral Dosage Forms That Should Not Be Crushed, sometimes known as the "Do Not Crush" list. From John F. Mitchell, Pharm.D, FASHP, Medication Safety Consultant, Canton, MI An updated list in PDF form.
ISMP and FDA are conducting a national campaign to eliminate the use of error-prone abbreviations in all forms of medical communications. This toolkit contains useful resources, including a brochure, print public service ad, and slide set.
Articles of Interest
Various articles of interest
Assessing Barcode Verification System Readiness in Community Pharmacies
Free tool to help community pharmacies identify what needs to be accomplished before implementing a barcode product verification system
Black Box Warnings emphasize significant and serious safety data for prescription drugs. This website provides listings of products with Black Box Warnings along with summaries of the warnings. From Joyce Generali, MS, RPh, FASHP, Director of Drug Information, Kansas University Medical Center.
Brochure for Consumers on Medication Misuse
This ISMP brochure helps educate consumers about the problem of inappropriate medication use and how their pharmacist can help them take medications correctly. It is part of a broader education campaign by ISMP and APhA; click here for more on the campaign and available tools.
Community Pharmacy Medication Safety Tools and Resources
ISMP tools that help community pharmacies and other ambulatory practice settings assess their medication safety practices and develop a medication safety program.
Effective approaches to standardization and implementation of smart pump technology
(CE for this continuing education program has expired)
Error-Prone Abbreviations List
Abbreviations, symbols, and dose designations that are frequently misinterpreted and involved in harmful medication errors. These items should NEVER be used when communicating medical information.
FDA Patient Safety News Videos
Downloadable and printable FDA broadcasts on patient safety issues, many of which feature information from ISMP.
FDA Safety Alerts
FDA safety alerts for drugs and medication-related medical devices
FMEA Process (with Sample FMEA)
Overview and additional resources for failure mode and effects analysis (FMEA), an ongoing quality improvement process employed to examine the use of new products processes to determine points of potential failure and what their effect would.
Documents with suggestions from ISMP on improving medication safety practices.
Guidelines for Preventing Medication Errors in Pediatrics
Article that appeared in the Journal of Pediatric Pharmacology and Therapeutics that concentrates on medication errors that are common in pediatrics facilities, with recommendations and strategies to reduce the potential for medication errors in those settings.
News series from the Agency for Healthcare Research and Quality
High-Alert Medication Modeling and Error-Reduction Scorecards (HAMMERS)
Free tool designed to help community pharmacies identify system and behavioral risk factors within their unique dispensing process and provide estimates of the impact of each risk factor on the overall likelihood that an error will reach the patient.
High-Alert Medications Consumer Leaflets
Consumer medication information leaflets for select high alert drugs that offer important safety tips for taking each medication safely. The leaflets are FREELY available for download and can be reproduced for free distribution to consumers.
HYDROmorphone Analgesic Potency Compared to Morphine
Here’s a useful tip created to help practitioners remember the equianalgesic potency of parenteral HYDROmorphone when compared to morphine sulfate. This tool is based on the 1:7 ratio often quoted in medical literature. Risk reduction strategies for reducing patient harm with HYDROmorphone are provided.
Improving Medication Safety with Anticoagulant Therapy
ISMP has compiled a variety of proactive tools, strategies, and resources to assist healthcare organizations identify and remediate error-prone practices that may exist when antithrombotic agents are prescribed, dispensed, and administered
IOM Report on Medication Errors
The Institute of Medicine (IOM) has conducted a Congressionally-mandated study of drug safety and quality, and the resulting report provides recommendations on identifying and preventing medication errors for consumers, healthcare providers, healthcare organizations, industry, and government agencies.
ISMP Assess-ERR™ Community Pharmacy Version
A medication system worksheet to assist community/ambulatory settings with error report investigation.
A medication system worksheet to assist with error report investigation.
ISMP Canada Chemotherapy Error Root Cause Analysis
ISMP Canada’s root cause analysis (RCA) report on a fatal fluorouracil overdose that occurred at an Edmonton, Alberta hospital. This full report, submitted to the Alberta Cancer Board, was publicly released in May 2007.
ISMP Confused Drug name List
Drug names that have been mistaken for one another, including look-alike and sound-alike name pairs.
ISMP High-Alert Medications
Drugs that bear a heightened risk of causing significant patient harm when used in error. Use this list to determine which medications require special safeguards to reduce the risk of errors.
ISMP Information and Resources on Sterile Pharmacy Compounding Safety
Links to ISMP statement, news release, and newsletter articles on sterile compounding safety issues and the need for more oversight of the sterile compounding process. Links to media coverage surrounding 2012 hepatitis outbreak due to contamination during sterile compounding of steroid injections are also provided.
ISMP List of Products with Drug Name Suffixes
A partial list of US drug and biological products whose names contain a suffix, including meanings of the suffix. Please note: this list does not include every currently marketed drug or biological product whose name contains a suffix.
ISMP Positions and Viewpoints
ISMP positions on key issues in medication safety and error prevention.
Links to other websites that contain helpful information and resources on patient safety.
Overview of Safety Recommendations for Medication Management Technology
Audio presentation with slides (CE for this continuing education program has expired)
Pathways for Medication Safety
Manuals on strategic planning, risk management, and assessing bedside bar coding readiness that help create a system-based approach to error prevention.
Pathways for Patient Safety™
Pathways for Patient Safety is a series of Web tools you can use to increase awareness, knowledge and implementation of best practices for reducing the risk of patient harm in physician practices. The free tools include: Working as a Team; Assessing Where You Stand; and Creating Medication Safety.
Patient-Controlled Analgesia: Making It Safer for Patients
(CE for this continuing education program has expired)
PCA Drug libraries: designing, implementing, and analyzing cqi reports to optimize patient safety
Monograph (CE for this continuing education program has expired)
Personal Medicine Form
Keeping an up-to-date list of medicines is an important strategy patients can employ to help protect them from a mistake. A personal medicine form developed by ISMP is available.
Quarterly Action Agenda (Free CE)
These agenda topics, which originally appeared in the ISMP Medication Safety Alert! Acute Care Edition, have been prepared for your organization and interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors.
These reports monitor serious adverse drug events reported to the FDA. They identify drug safety trends, report potential safety issues, and seek to improve the system.
Example of a health care Failure Mode and Effects Analysis for anticoagulants. The severity of each failure mode has been scored. However, since the probability of each failure and its ability to be detected before causing patient harm will vary from organization to organization, these scores have been omitted so that each organization can make its own assessment of these vulnerabilities.
ISMP tools that help healthcare organizations assess their medication safety practices and compare aggregate data with other similar organizations.
Standard Concentrations of Neonatal Drug Infusion
A collaborative effort between the Institute for Safe Medication Practices (ISMP) and Vermont Oxford Network (VON)
Tall Man Letters
The sets of look-alike drug names in this tool have been modified using “tall man” letters to help draw attention to the dissimilarities in their names. Several studies have shown that highlighting sections of drug names using tall man (mixed case) letters can help distinguish similar drug names, making them less prone to mix-ups.
Corrections for errors in published medical literature.
The Root Cause Analysis Workbook for Community/Ambulatory Pharmacy
The Root Cause Analysis Workbook for Community/Ambulatory Pharmacy, provides access to a coordinated, extensive set of tools designed to assist pharmacists in the process of minimizing the occurrence of medication errors.
Throw Away Your Old Medicines Safely
Information for safely throwing away old medicines