Top 10 Medication Errors and Hazards from 2020

ISMP has identified the Top 10 Medication Errors and Hazards that appeared in the ISMP Medication Safety Alert! during 2020. The list is not based only on the most frequently reported problems or those that have caused the most serious consequences to patients, although these factors were considered. Instead, we identified errors and hazards that have been persistent and can be avoided or minimized with system and practice changes. Two of the Top 10 Medication Errors and Hazards are closely associated with the COVID-19 pandemic—errors with the COVID-19 vaccines and hazards associated with positioning infusion pumps outside of COVID-19 patients’
rooms. In addition to the two pandemic-related hazards, we believe the other eight issues warrant attention and priority in the coming year.

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