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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We received more than 400 responses to a survey on IV vincristine safety practices published in our December 4, 2005, newsletter, which was prompted by yet another death from intrathecal administration of IV vincristine. Overall, results showed that pediatric, outpatient, and specialized oncology...
Error-reporting systems represent one of the primary means by which healthcare providers learn about: Potential risks : hazardous conditions hidden in processes Actual errors : errors that occur during the delivery of patient care C auses of errors : underlying weaknesses in systems and processes...
Problem : In our November 3, 2005 newsletter, we reported an error that resulted from pressing a number key once on an Alaris SE pump (formerly Signature Edition GOLD Infusion System ) and getting an unintended repeat of that same number (i.e., the pump recorded 366 mL per hour, not 36 as intended)....
With the advent of Medicare Part D and the wide variety of insurers and prescription drug plans, it's likely that more patients will be relying in part on mail service pharmacies for fulfillment of their prescription drugs. Last week, we received a media release about a newly published study that...
The V.A.C. INSTILL SYSTEM by KCI is a wound healing system that facilitates automated delivery of topical solutions to wound sites. While very different from an infusion pump, the device is programmed to deliver a desired rate of infusion; but it lacks protection from gravity free-flow if the tubing...
Problem: Neuromuscular blocking agents have been inadvertently administered to patients who were not receiving proper ventilator assistance. Because the respiratory muscles were paralyzed, some patients have died or sustained serious, permanent injuries. In fact, the USP-ISMP Medication Errors...
Our 2005 field test results clearly show that, with few exceptions, little improvement has occurred during the past 6 years with pharmacy computer systems to safeguard against medication errors. Alarming findings from our 1999 field test demonstrated that pharmacy computer systems in this country...
Healthcare is a complex, error-prone industry. However, other complex, error-prone industries, such as aviation and nuclear arms handling, have much better safety records than healthcare. The fundamental differences between these industries, known as high-reliability organizations (HROs), and...
Healthcare is a highly complex, error-prone industry. From treating patients in a hectic emergency department to the daily pressures of dispensing thousands of medications, the delivery of healthcare exemplifies an unprecedented level of non-stop activity, specialization, and intricate...