Use this list to determine which medications require special safeguards to reduce the risk of errors and minimize harm.
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.
All Resources
This list includes look-alike and sound-alike name pairs. Use this list to determine which medications require special safeguards to reduce the risk of errors and minimize harm.
Beyond Blame is a must-see for all who are responsible for patient care. The award-winning DVD introduces viewers to “Just Culture,” a way of thinking that fixes problems rather than assigning fault.
Problem: National news recently exposed details about a 2017 fatal medication error that happened at a large, prestigious hospital after the Centers for Medicare & Medicaid Services (CMS) briefly placed its Medicare reimbursement status in jeopardy. The hospital’s status was quickly restored...
Electronic health records (EHRs), electronic prescribing (e-prescribing), and other health information technology (HIT)-related tools are a mainstay in healthcare, and their introduction has brought about significant changes in how medications are prescribed, dispensed, and administered. If the...
Healthcare practitioners should use the exact metric weight when writing drug orders. This poster discourages prescribing only by volume or dosage limit, which can be ambiguous, and provides a correct sample order.
Healthcare practitioners should always prepare liquid oral medications in oral syringes. This poster emphasizes that the tips on oral syringes make it more difficult or impossible to accidentally administer the oral medication intravenously.
Verbal and telephone medication orders can be misheard, misunderstood, or mistranscribed. This poster gives healthcare practitioners a checklist for safe order communication.
When drug names are abbreviated, they may be misunderstood, resulting in patient harm or time wasted clarifying ambiguous orders. This poster presents examples of orders where the intended drug/dose was misunderstood and counsels healthcare practitioners to always spell out drug names.