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...
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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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...
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...
Students Have a Key Role in a Culture of Safety: Analysis of Student-Associated Medication Incidents
Undergraduate and postgraduate students in healthcare fields are attempting to develop the skills required to deliver safe and effective patient care as future practitioners. As part of their training, most students are exposed to a variety of practice environments and direct patient care...
ISMP has repeatedly cautioned about abbreviating drug names due to the risk of misinterpretation. One recurring problem has been with tPA, an abbreviation often used for alteplase (ACTIVASE), the first tissue plasminogen activator approved by the US Food and Drug Administration (FDA). This...
Between November 2017 and March 2018, ISMP conducted three surveys to learn about current practices with smart infusion pumps that have dose error-reduction software (DERS). Smart pumps can vastly improve medication safety by providing customizable libraries with dose limits and administration rates...