Problem: Earlier this month, we were notified about two cases of accidental intraspinal injection of tranexamic acid, occurring in two different states. Unfortunately, the report was sent anonymously, and we were unable to learn additional details about the events, including the outcome of each...
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: Anecdotal support, public opinion, and state laws in the US are outpacing scientific research involving medical marijuana, more professionally known as medical cannabis. Medical cannabis differs from the street product in that the plant must be reliably grown and handled in a manner that...
According to the Centers for Disease Control and Prevention (CDC), nearly 4 million infants are born in the US each year, including approximately 132,000 multiple births. 1 Unique characteristics of this newborn population pose significant challenges regarding accurate patient identification, which...
Since 1994, when ISMP first became the nation’s only nonprofit organization devoted entirely to preventing medication errors, we have served as a vital force for progress in medication safety through our unyielding advocacy and the development of resources and learning opportunities for healthcare...
The latest issue of ISMP’s Quarter Watch™ (see description in box below) focuses on two older but widely used analogs of the inhibitory gamma-aminobutyric acid (GABA) neurotransmitter and a new type of antipsychotic medication approved for Parkinson’s disease psychosis. Key findings include:...
Since January 2019, ISMP has learned about 4 children who received vin CRIS tine erroneously by the intrathecal route of administration, each suffering a very painful death. Three of the children were from Guyana, and one was from Norway. The child from Norway had a brain tumor and was just 6 years...
Most people are aware of the need to keep medications out of children’s reach, but they don’t necessarily realize that similar rules apply when it comes to keeping pets safe. Pets can also get into medications that are not intended for them, which could cause harm. One case in point was recently...
Medication-related warning systems are often used to inform both practitioners and consumers about new risks, or remind them about known risks associated with the use of medications. The warning system may ask the recipient to choose between two or more courses of action, present only one safe...
ISMP was shocked and saddened to learn that, once again, 1-4 a frontline healthcare practitioner has found herself on the receiving end of a criminal indictment after making a medication error that led to the tragic death of a patient. RaDonda Vaught, a 35-year-old registered nurse, was indicted on...