ISMP Medication Safety Alert!®

Acute Care

A valuable resource to reduce medication error risk in your hospital

The ISMP Medication Safety Alert!® Acute Care is a 4-5 page digital newsletter, published every two weeks for hospital healthcare professionals.  Practitioners are encouraged to share this publication at committee meetings to initiate conversations about preventing similar errors within their organizations.

Who reads this newsletter? 

  • Directors of Pharmacy
  • Pharmacists
  • Nurses
  • Physicians
  • Medication and Patient Safety Officers
  • Risk Managers
  • Product Managers
  • Anyone concerned with medication safety

Subscription Information

  • Twenty-five (25) issues per year
  • One-year subscription rate: $191.00
  • Distributed via email on a bi-weekly basis
  • Special pricing for group purchases; contact ISMP 


Browse Issues

This week's featured article: Recommendations for practitioners to prevent vaccine errors Part 2: Analysis of ISMP Vaccine Errors Reporting Program (ISMP VERP)

The US Food and Drug Administration (FDA) and ISMP have received reports of medication errors involving 10-fold topotecan overdoses. One error was due to misreading an order caused by omission of the leading zero in the dose. The topotecan dose was written as .7 mg instead of 0.7 mg, and the patient received 7 mg of the drug in error. 

Four other 10-fold overdoses have also been reported. None of these reports indicated the root causes. However, the overdoses in three of the cases may have occurred because the decimal point in the dose was overlooked when interpreting the topotecan order. In...