The Perils of Polypharmacy

The term “polypharmacy” most commonly refers to a situation where a patient is being treated with many, five or more, medications. Patients of all ages may potentially receive many medications. The...

Errors Associated with Paxlovid

Paxlovid was authorized under the emergency use authorization (EUA) by the US Food and Drug Administration (FDA) in December 2021 and is used for mild-to-moderate coronavirus 2019 (COVID-19)  in ad...

The Pursuit of Prevention – Confronting Drug Diversion

Drug diversion is a serious problem that affects patients’ and health professionals’ safety. Patients may suffer from suboptimal therapy if their medications were diverted, receive substandard care...

Introducing ISMP’s New Targeted Medication Safety Best Practices for Community Pharmacy: 2023-2024

Join ISMP for a complimentary webinar as we seek to inspire and mobilize practitioners from around the US in the national adoption of specific consensus-based safe practices selected to reduce or e...

Errors Associated with COVID-19 Vaccines

In December 2020, the US Food and Drug Administration (FDA) granted emergency use authorization (EUA) to both the Pfizer-BioNTech and Moderna coronavirus disease 2019 (COVID-19) vaccines. Since the...

International Medication Safety Update

Around the world numerous organizations are tirelessly working to make medication-use systems safer. While the focus of these organizations may differ, they all share a common goal of ensuring that...

Human Factors Role and Considerations in Drug Labeling and Packaging

Human error can be described as a failure of a common sequence of psychological functions that are basic to human behavior. This failure involves perception of the situation, the way these stimuli ...

Call to Action: Experience in Adopting the ENFit System to Guard Against Accidental Tubing Misconnections

Catheter misconnections involving enteral-to-IV tubing are well documented in the patient safety literature.  They often lead to severe consequences for patients and families. Despite the recent ad...

Sterile Compounding Technology: Pharmacy Technicians Lead the Adoption of Best Practices

Over the past 10 years there has been increased growth and maturity in the compounding technology market and an increased uptake by pharmacies in the use of sterile compounding technologies. Pharma...

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error

Are you troubled by the criminalization of a medical error that recently occurred within a present-day healthcare organization? How do we come to the right conclusions about accountability? Are you...

Engaging the OR and Procedural Areas to Mitigate Risks with Controlled Substance Medications

Workflow processes in ORs and procedural areas can contribute to an environment vulnerable to drug diversion. Broad access to a variety of medications, delays in documentation, rapid patient turn o...

Quantifying the Holistic Costs of Controlled Substance Medication Waste

The availability of opioid medication quantities and doses above what is typically prescribed for patients is a known medication safety and diversion risk because it requires practitioner manipulat...