In July and August 2018, we invited practitioners who administer intravenous (IV) push medications to adults to participate in a survey. 1 The survey was conducted in response to three prior ISMP surveys that revealed numerous risky practices associated with the administration of IV push medications...
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
Problem: Glucose testing is one of the most frequent point-of-care (POC) tests performed in hospitals. 1 While POC glucose testing offers immediate results that can be used to make important clinical decisions about the treatment of hypo- or hyperglycemia, errors can occur at any point in the...
You may have noticed changes in the units of measure on the labels of over-the-counter (OTC) fat-soluble vitamins (A, D, and E) from international units (IU) to metric units of measure—micrograms (mcg) or milligrams (mg). For example, aqueous vitamin D oral drops previously labeled as 400...
Problem: Within weeks of each other, two hospitals have reported mix-ups between epidural analgesia and intravenous (IV) antibiotics in labor and delivery (L&D) units. These mix-ups mimic previously published events and have similar contributing factors including look-alike infusion bags, overlooked...
Problem: Inadvertent tubing misconnections pose a significant risk to patients. They often occur when luer-compatible tubing is mistakenly connected to another type of tubing into which it can fit but for which it was not designed. To help prevent dangerous misconnections, the International...
In the latest issue of ISMP’s Quarter Watch , we examine a full year of adverse drug event reports received by the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) during 2017, to identify the most frequently named suspect drugs in four distinctive and severe adverse drug...
Between June and July 2018, ISMP conducted a survey on high-alert medications in acute care settings to learn about possible additions or deletions before updating our longstanding list. High-alert medications are an essential component of drug therapy, but they carry a significant risk of causing...
A Safety Brief in the June 28, 2018, ISMP Medication Safety Alert! noted a change in concentration for rabies immune globulin (human) ( HYPERRAB ) manufactured by Grifols. Since a higher concentration allows for more efficient wound infiltration (i.e., more of the immune globulin can be delivered to...
Methotrexate is a folic acid antagonist that was originally approved to treat a variety of cancers. Used for oncologic indications, methotrexate is administered in cyclical frequencies and in variable doses based on body surface area and the type of cancer being treated—for example, 12 g/m 2 per...