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...

Mix-ups Between Epidural Analgesia and IV Antibiotics in Labor and Delivery Units Continue to Cause Harm

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 previ...

Investigational Drugs: Strategies for Sponsors, FDA, and Clinical Sites to Prevent Product-Related Errors (Part II)

Limited regulatory guidance exists for investigational drug labeling, packaging, and nomenclature, exposing sites that participate in clinical trials to many troubling product-related safety risks....

Investigational Drugs: Product-Related Issues Pose Significant Challenges (Part I)

An investigational drug is a chemical or biological substance that has been tested in the laboratory and approved by the US Food and Drug Administration (FDA) for testing in people during clinical ...

Using Information From External Errors to Signal a “Clear and Present Danger”

Chances are you’ve scanned the headlines and read many of the stories about medication errors published in the ISMP Medication Safety Alert!, particularly the tragic errors. Just a few examples of ...

Reporting and Second-Order Problem Solving Can Turn Short-Term Fixes into Long-Term Remedies

Problem: Healthcare practitioners are repeatedly challenged by unexpected problems they encounter due to both large and small work system failures that hinder patient care. A medication needed for ...