Total Systems Safety Supports Practitioners in Partnering with Families to Protect Patients

Problem: The National Steering Committee for Patient Safety1 was developed and coordinated by the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ...

Survey Shows Room for Improvement with Three New Best Practices for Hospitals

In our February 22, 2024 newsletter, we invited hospitals to participate in a short survey to establish a baseline of implementation for the three new Best Practices released in the 2024-2025 ISMP ...

Call to Action: Standardization and Smarter Logic Needed to Prevent Drug Name Selection Errors

Problem: Since 2019, ISMP has recommended entering, at a minimum, the first five letter characters of a drug name (unless the name has fewer than five letters) during searches in automated dispensi...

How to Navigate the New ISMP Website

ISMP has a new website (www.ismp.org) that has been integrated with the website of our affiliate organization, ECRI, to help simplify sign-ins and streamline access to our many services and product...

Kentucky law prevents practitioners from being criminally charged for medical errors

We were pleased to learn that Kentucky Governor Andy Beshear recently signed a bill (House Bill 159) into law that protects healthcare practitioners from being criminally charged for medical errors...

ISMP Urges Increased Action at the Practice Level to Halt the Growing Danger of Counterfeit Drugs

Problem: Counterfeit drugs, or fake drugs, made to resemble genuine pharmaceutical manufacturers’ medications (Figure 1), have been a longstanding threat to the health and safety of patients. Alarm...

List of Error-Prone Abbreviations

This list includes abbreviations, symbols, and dose designations that have been frequently misinterpreted and involved in harmful or potentially harmful medication errors.

Implement Strategies to Prevent Persistent Medication Errors and Hazards: 2024

Reflecting on events that occurred in 2023, we have identified the top three medication errors and hazards that were recurring themes in the ISMP Medication Safety Alert!, which our affiliate ECRI,...

Three New Best Practices in the 2024-2025 Targeted Medication Safety Best Practices for Hospitals

ISMP has released its 2024-2025 Targeted Medication Safety Best Practices for Hospitals, whose purpose is to identify, inspire, and mobilize widespread, national adoption of consensus-based Best Pr...

High-Alert Medications in Acute Care Settings

Medications requiring special safeguards to reduce the risk of errors and minimize harm.

Why “Benchmarking” Error Rates Is NEVER a Good Measure of Performance or Patient Safety

Problem: Organizations often want to know, in comparison to their peers, how they stand in achieving and maintaining an environment that promotes patient safety. Benchmarking is a process that can ...

Minimizing Distractions and Interruptions During Medication Safety Tasks

Problem: A distraction occurs when an individual’s attention is drawn away from one task to a different task, or when they are trying to work on multiple tasks at the same time. An interruption occ...

Key Elements of Medication Use

Medication use is a complex process that comprises the sub-processes of medication prescribing, order processing, dispensing, administration, and effects monitoring. The Key Elements of the Medicat...

Pump Up the Volume: How to Prioritize Events and Analyze Error Data

Problem: Error reports can be used to identify local system hazards, provide analysis of uncommon events, share lessons within and across organizations, and improve patient safety culture.1 In our ...

Look-Alike Drug Names with Recommended Tall Man (Mixed Case) Letters

Drug name pairs or larger groupings that look similar utilize bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names.

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...

Isoflurane Labeled “For Animal Use Only” in Cartons of Isoflurane Intended for Human Use

ISMP has received reports from several healthcare institutions that recently received cardboard cases labeled “Isoflurane USP 100 mL” by Piramal Critical Care (NDC 66794-017-10) (Figure 1) that act...

Medication Safety and Error Prevention: Efforts Should Focus on Systems Solutions

Many people take medicine without enough thought to medication safety issues, such as following dosage directions, being aware of medication interactions and side-effects, or weighing other importa...

Guidelines for Safe Medication Use in Perioperative and Procedural Settings

Developed to support hospitals, ambulatory surgery centers, and other procedural locations in addressing identified national gaps in perioperative and procedural medication safety.

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...

NAN Alert! Potassium Chloride for Injection Concentrate in EXCEL Plastic Bags

B. Braun recently announced a new presentation of potassium chloride for injection concentrate (2 mEq/mL) in a 250 mL EXCEL container plastic bag with blue and red labeling, and a blocked medicatio...