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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In our July 24, 2003 issue, we provided an example of how color-coding can contribute to medication errors. Specifically, we mentioned how a color-coding system for the pharmacologic class of ophthalmic medications, along with similar corporate logos, fonts, and package sizes, have led to numerous...
Patient-controlled analgesia (PCA) has considerable potential to improve pain management.However, errors happen frequently, sometimes with tragic consequences. In Part I, published in our July 10, 2003 newsletter, we described how PCA errors happen. Part II presents a checklist of efforts related to...
Patient-controlled analgesia (PCA) has considerable potential to improve pain management for patients, allowing them to self-administer more frequent but smaller doses of analgesia. When used as intended, PCA actually reduces the risk of oversedation, which is an unintended consequence of the more...
PROBLEM: Accidental administration of concentrated epinephrine has been discussed before in our newsletter. As mentioned in one recent issue 1 many errors can be traced to confusion with expressing the concentration as a ratio strength rather than a metric weight per volume. But another reason for...
Recently, when a nurse couldn’t find an enteral feeding set, she improvised and spiked the bottle’s cap with IV tubing. Since the enteral pump would not accept the IV tubing, she used an IV pump to deliver the feeding. The patient was being weaned off a three-in-one total parenteral nutrition (TPN)...
Figure 1. Problem: The treatment of severe hypernatremia can be challenging, especially in patients with preexisting conditions that may seem to limit therapeutic options. Such a situation recently resulted in an ill-conceived decision to give sterile water for injection IV to an elderly patient who...
PROBLEM: Several incidents have been reported where undiluted epinephrine 1:1,000 (1 mg/mL) was given IV to patients instead of using the 1:10,000 (0.1 mg/mL) concentration. In each case, the more diluted epinephrine (1:10,000) was available for use, but staff inadvertently prescribed or selected...
Problem: A 72-year-old woman underwent cancer surgery and her surgeon prescribed patient controlled analgesia (PCA) with a 2 mg morphine loading dose and 1 mg every 10 minutes prn (6 mg maximum per hour). Initially, the patient was restless and agitated in the post anesthesia care unit, but she...
ISMP urges hospitals, community pharmacies, and other locations that use opium tincture and/or paregoric (camphorated tincture of opium) to take action immediately to minimize the risk of fatal confusion between these drugs. Last week, a Connecticut newspaper reported that a 51-year-old woman with...