Latent and Active Failures Perfectly Align to Allow a Preventable Adverse Event to Reach a Patient

Problem: A physician prescribed 2 g of intravenous (IV) magnesium sulfate for a patient in palliative care to treat hypomagnesemia. To administer the dose, a night nurse went to an automated dispen...

Adopt Strategies to Manage Look-Alike and/or Sound-Alike Medication Name Mix-Ups

ISMP has long advocated for increased awareness of look-alike and/or sound-alike medication name mix-ups and the implementation of safeguards to prevent them. To support this advocacy, ISMP maintai...

Criminalization of Human Error and a Guilty Verdict: A Travesty of Justice that Threatens Patient Safety

On March 25, 2022, most of the healthcare community were shocked and dismayed after learning that RaDonda Vaught had been convicted of criminally negligent homicide and gross neglect of an impaired...

Addressing Disrespectful Behaviors and Creating a Respectful, Healthy Workplace–Part II

In late 2021, ISMP conducted a survey on disrespectful behaviors in healthcare. Any behavior that discourages the willingness of staff or patients to speak up or interact with an individual because...

Survey Suggests Disrespectful Behaviors Persist in Healthcare: Practitioners Speak Up (Yet Again) – Part I

In our September 9, 2021 newsletter, we discussed the topic of disrespectful behaviors, which have persisted in healthcare for years. Unfortunately, too many remain silent or make excuses in an att...

Additional Strategies to Improve Complete Delivery of Small-Volume Intermittent Infusions

In the December 3, 2020 newsletter, ISMP published an article to remind practitioners that up to half of the medication in a 50 mL small-volume intermittent infusion (medication diluted in a small ...

A Recurring Call to Action: Every Healthcare Organization Needs a Medication Safety Officer!

Medication safety is a serious responsibility that is vital to the sustainability of healthcare organizations.1 On average, hospitalized patients experience one medication error each day,2,3 and pr...

Hidden Medication Loss When Using a Primary Administration Set for Small-Volume Intermittent Infusions

While covering for a colleague during patient rounds in an adult medical unit, a pharmacist noticed two empty 50 mL minibags of ZOSYN (piperacillin and tazobactam) hanging on a patient’s intravenou...

The Differences Between Human Error, At-Risk Behavior, and Reckless Behavior Are Key to a Just Culture

Do you believe your organization operates within a Just Culture? We have asked this question many times while working collaboratively with healthcare organizations and professionals. It is not an e...

Speaking Up About Patient Safety Requires an Observant Questioner and a High Index of Suspicion

Healthcare practitioners are expected to speak up about patient safety concerns to help intercept errors and avoid adverse patient outcomes. By ‘speaking up,’ we mean raising concerns for the benef...

Independent Double Checks: Worth the Effort if Used Judiciously and Properly

Manual independent double checks of certain high-alert medications have been widely promoted in healthcare to help detect potentially harmful errors before they reach patients.1,2 Many practitioner...

Dangerous Wrong-Route Errors with Tranexamic Acid—A Major Cause for Concern

Problem: Earlier this month, we were notified about two cases of accidental intraspinal injection of tranexamic acid, occurring in two different states. Unfortunately, the report was sent anonymous...