In the latest issue of ISMP’s Quarter Watch™ , we examine the adverse drug events reported to the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) for 97 new drugs and biological products approved between 2015 and 2017, including: evolocumab ( REPATHA ) and alirocumab (...
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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Introduction One in every 1,000 medication orders in a hospital, and one in every 1,000 prescriptions in a pharmacy, have been associated with selecting the wrong drug while prescribing, transcribing, dispensing, or administering medications. 1-4 Drug name similarities are a primary cause of these...
ISMP has launched a new tool to help healthcare facilities identify and manage targeted risks associated with the use of IV push medications in adults. The ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices is designed to assist practitioners in evaluating their practices,...
Problem: In our November 1, 2018 newsletter, we shared the findings from a recent 2018 ISMP survey of 977 practitioners (mostly nurses) on adult intravenous (IV) push medication practices and compared these results to related ISMP surveys conducted between 2010 and 2014. The 2018 survey revealed...
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...
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: 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...
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...