October 2014

In this month’s issue:

  • Side tracks on the safety express: Interruptions lead to errors and unfinished… Wait, what was I doing? The risk of any medication error increases with each interruption, and the risk of a harmful medication error is doubled when nurses are interrupted 4 times during drug administration and tripled when interrupted 6 times.  This article discusses how interruptions and distractions cause medication errors and some suggest strategies for reducing interruptions and distrations on the medication process.


  • SafetyWires:Discusses recently reported errors in long-term care facilities caused by misinterpreting medication administration frequencies on some electronic hospital discharge summaries, and by accepting a "pop-up" medication after entering only a few letters into a computerized order entry system.


  • Message in our Maiilbox.  Corrects the appropriate beyond-use date (expiration date) of oral over-the-counter medications that was stated in our last issue. 


Report medication errors to ISMP. Share your medication safety stories and error reports in confidence by calling ISMP 1-800-FAILSAF(E), via our website (, or by email ( Reporter identity and location remain strictly confidential and are never published. Anonymous reports are also accepted. 

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