Resource Library

Whether you have experienced a medication error in your organization or you are proactively implementing prevention strategies, you are not alone. Thousands of organizations worldwide have relied on ISMP's resources for institutional change to reduce errors on a daily basis. These resources are developed from ISMP's review of reports through its national error reporting programs, peer-reviewed articles in its publications, and/or consensus gathering summits on topics pertinent to specific errors  or hazards. ISMP offers a wide range of downloadable and easy to use resources. Many are free.

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In our June 12, 2003 newsletter, we reported several cases in which the tubing from a portable blood pressure monitoring device was inadvertently connected to the patient’s IV line – in one case, leading to a fatal air embolism. In our September 4, 2003 issue, we wrote about an inadvertent...
Problem: Have you ever used IV tubing and/or an IV pump to administer an oral solution or liquid nutrition to patients via a gastric or nasogastric tube? Before you say "no," don't overlook the potential for purposefully using this method of delivering enteral solutions. For example, GoLYTELY bowel...
More than 2,000 hospital nurses, pharmacists, and others who responded to our November 13, 2003 survey on workplace intimidation, offered a daunting glimpse of an apparent culture of disrespect among healthcare providers. Our survey results, covered in our March 11, 2004 issue , clearly showed that...
All too often, seasoned healthcare providers feel compelled to warn new staff members about a particularly difficult physician, and perhaps even shield them from this person for as long as possible. It's a telling sign of a culture that tolerates, even fosters, intimidation. More than 2,000 (N=2,095...
In our July 24, 2003 issue, we provided an example of how color-coding can contribute to medication errors. Specifically, we mentioned how a color-coding system for the pharmacologic class of ophthalmic medications, along with similar corporate logos, fonts, and package sizes, have led to numerous...
Patient-controlled analgesia (PCA) has considerable potential to improve pain management.However, errors happen frequently, sometimes with tragic consequences. In Part I, published in our July 10, 2003 newsletter, we described how PCA errors happen. Part II presents a checklist of efforts related to...
Patient-controlled analgesia (PCA) has considerable potential to improve pain management for patients, allowing them to self-administer more frequent but smaller doses of analgesia. When used as intended, PCA actually reduces the risk of oversedation, which is an unintended consequence of the more...
PROBLEM: Accidental administration of concentrated epinephrine has been discussed before in our newsletter. As mentioned in one recent issue 1 many errors can be traced to confusion with expressing the concentration as a ratio strength rather than a metric weight per volume. But another reason for...
Recently, when a nurse couldn’t find an enteral feeding set, she improvised and spiked the bottle’s cap with IV tubing. Since the enteral pump would not accept the IV tubing, she used an IV pump to deliver the feeding. The patient was being weaned off a three-in-one total parenteral nutrition (TPN)...