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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What do all these medication errors have in common? A patient who was transferred from one hospital to another received a duplicate dose of insulin because the receiving nurse didn't know the medication had been given before transfer. The patient's medication history had not been provided to the...
Medications are among the most common interventions used to improve health. So it should come as no surprise that adverse drug events – injuries caused by the use of medications – are a substantial source of preventable harm to hospitalized patients. Measuring the level of safety is fundamental to...
Problem: Recently, we learned that an oxygen flow meter had been forced into a nitrous oxide wall outlet that was directly adjacent to an oxygen outlet in a radiology suite. The oxygen flow meter's index safety system, designed to assure connection only to oxygen wall outlets, was broken at the time...
Problem : As we began our Thanksgiving holiday last week, we were saddened to hear the news of yet another tragic medication error that claimed the life of a 69-year-old Seattle woman, caused in large part by unlabeled basins of solution in the interventional radiology procedure room. During coil...
The recent death of a 16-year-old boy due to an epinephrine overdose has further highlighted ongoing serious problems with epinephrine labeling and nomenclature. Two factors that contribute to errors include: (1) lack of understanding of the difference between dose concentrations (such as 1:1,000 or...
One of the treatments for priapism (prolonged painful erection that occurs without sexual stimulation) is to inject an alpha-agonist — phenylephrine or epinephrine, for example — into the penis (intracavernous injection). This causes vessels to narrow and reduces blood flow. The procedure typically...
Problem: Last month we learned about three errors with lomustine (CeeNU) that sounded hauntingly similar to methotrexate errors we reported in our April 3, 2002 newsletter. When used to treat rheumatoid arthritis and other non-oncologic conditions, a single dose of oral methotrexate should be taken...
In our June 12, 2003 newsletter, we reported several cases in which the tubing from a portable blood pressure monitoring device was inadvertently connected to the patient’s IV line – in one case, leading to a fatal air embolism. In our September 4, 2003 issue, we wrote about an inadvertent...
Problem: Have you ever used IV tubing and/or an IV pump to administer an oral solution or liquid nutrition to patients via a gastric or nasogastric tube? Before you say "no," don't overlook the potential for purposefully using this method of delivering enteral solutions. For example, GoLYTELY bowel...