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.

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At first glance, medication error rates may seem ideal for benchmarking. Yet, we must question the wisdom of applying the benchmarking concept to the medication use process when the focus is on error rates. The true incidence of medication errors varies, depending heavily on the rigor with which the...
The "jury is in" on the case of the nurse charged with criminally negligent homicide in an infant’s death from a medication error. After about 45 minutes of deliberation, the jury not only acquitted the nurse, but the jurors also offered their support, crying and hugging the nurse after the verdict...
In 1997, there were some great strides forward as well as a few steps back in medication error prevention. We felt that recognition was due for both, and so, without further ado, here are ISMP's top CHEERS and JEERS: CHEERS to the pharmaceutical companies responsive to product labeling, packaging,...
Problem: We have received several reports about incidents where, because containers were not labeled, patients received incorrect products. In the first incident, a 37-year-old male patient's genitals were severely burned when his university hospital-based physician mistakenly applied T.B.Q.® (a...
The January 31, 1996, issue of ISMP Medication Safety Alert! discussed the case of a 7-year old boy who died following what should have been routine surgery to remove scar tissue and a benign tumor from his left ear. Further details and the hospital's reaction to the devastating news that a...
If all pharmaceutical and medical device manufacturers used error prevention analysis (EPA) - a trouble-shooting process introduced to the health care community by ISMP and now encouraged by the US Food and Drug Administration (ISMP Medication Safety Alert!, Oct 9, 1996) - they would save money and...