Imported Fluid Product Checklist

This tool was developed to assist organizations in conducting a gap analysis when evaluating imported products safety during the fluid shortage crisis following the Hurricane Helene aftermath.

Palliative Care Access for Indigenous Populations: Removing Barriers and Reducing Disparities

Palliative care is a type of specialized medical care for patients living with terminal medical conditions. The goal of palliative care is to alleviate patients’ suffering and to improve their qual...

The Four Greatest Weaknesses in the American Healthcare System Fueling Preventable Harm

Every clinician swore an oath to “do no harm,” and yet, while unintentional, preventable harm is inflicted on patients every day in healthcare.   For decades, valiant efforts have been underway to ...

Balancing Disinfection and Manufacturer Recommendations in Ultrasound Technologies

Introduction As the use of ultrasound technology continues to expand across various medical disciplines—from radiology and cardiology to point-of-care applications—ensuring appropriate and effectiv...

Weathering the storm— Safety considerations during fluid shortages

Problem: As most readers are aware, on September 29, 2024, Baxter announced that their North Cove, NC manufacturing plant was temporarily closed due to damage from Hurricane Helene. This facility i...

ISMP National Vaccine Errors Reporting Program 2022-2023 Analysis: New Vaccines, New Errors

Problem: Though immunization is one of the greatest public health achievements, continued success relies on the appropriateness with which vaccines are prescribed, dispensed, stored, and administer...

Vaccine Bi-Annual Report

An analysis of vaccine error reports submitted to the ISMP National Vaccine Errors Reporting Program (ISMP VERP) during calendar years 2022 and 2023.

Drug Diversion and Infection Prevention: When the Needle Hits the Vein

Longtime infection prevention leaders likely remember the story of David Kwiatkowski—a healthcare worker whose drug diversion activities put thousands of patients at risk of hepatitis C infection. ...

Reducing Inappropriate Polypharmacy through Deprescribing

Polypharmacy refers to the simultaneous use of multiple medications. It can lead to risks such as drug interactions, increased side effects, medication non-adherence, and cognitive impairment. Lear...

Supporting Nurses in Transition: Addressing Patient Safety Concerns in 2024

For 2024, one of the most pressing concerns in healthcare is ensuring the safe and effective transition of new nurses from their education into clinical practice. As the frontline of patient care, ...

Understanding “Human Factors” is Not “Factors Associated with Being Human”

Modern healthcare relies on a variety of physical and digital assets and tools. Sophisticated medical devices help in diagnosing and treating disease. Advanced materials prevent the spread of bacte...

Can We Ensure Medication Safety with the Use of Speech Recognition Software?

Problem: Speech recognition, or speech-to-text, is the ability of a computer software system to identify spoken words and then convert them into readable text. It is something most people use daily...

Advancing Safe and Equitable Healthcare: The New Patient Safety Structural Measure by CMS

On July 31, 2024, the Centers for Medicare & Medicaid Services (CMS) announced a significant update to the hospital quality reporting program with the finalization of the Patient Safety Structu...

Use Barcode Scanning to Prevent Errors with Enteral Nutrition Feedings

Problem: The safe use of enteral nutrition (EN) in the hospital setting is often taken for granted. However, when viewed closely, the process is often fraught with potential failure points. Challen...

Five Key Takeaways on Video-Based Patient Monitoring for Preventing Falls

ECRI named ongoing challenges related to patient falls as one of its 2024 Top 10 Patient Safety Concerns because falls continue to be the number one sentinel event reported to the Joint Commission ...

NAN Alert! Manufacturer’s dexmedeTOMIDine premixed IV bags may be packaged within an overwrap labeled as acetaminophen

A Hikma product with an overwrap labeled acetaminophen injection 1,000 mg/100 mL (NDC 0143-9386-01,  lot  number  24070381, expiration date 09/2025) (Figure 1), may contain a dexmedeTOMIDine 400 m...

Navigating the Complexities of Dementia Diagnosis: The Path to Diagnostic Excellence

Understanding the diagnosis of dementia is essential for medical professionals, patients, and caregivers. Unlike many medical conditions that are diagnosed through straightforward testing, diagnosi...

List of Confused Drug Names

Also known as the Look-alike and sound-alike (LASA) list.

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...

How American Emergency Departments Are Missing Older Adult Abuse

A recent report in the Journal of the American Geriatric Society (JAGS) suggests that emergency departments (EDs) have opportunities to improve how they identify cases of older adult abuse and how ...

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 ...