Survey Exposes Risks with Custom and Multi-Chamber Bag Parenteral Nutrition—Part I

PROBLEM: Parenteral nutrition (PN) is a complex life-sustaining therapy for patients who cannot intake adequate oral or enteral nutrition. It can contain more than 40 ingredients and is considered ...

A Deeper Dive into Active Failures and Accountability Using Just Culture Principles—Part II

PROBLEM: In our last newsletter, in the main article, Another case of nursing criminalization – Long-term care facilities must improve systems, not blame nurses - Part I, we discussed how a series ...

Another Case of Nursing Criminalization—Long-Term Care (LTC) Must Improve Systems, Not Blame Nurses—Part I   

This ISMP Medication Safety Alert!® Acute Care newsletter article describes another case in which a nurse, this time working in long-term care (LTC), was criminally indicted after a patient died du...

MERP Annual Review Exposes How Manufacturer Labeling/Quality Issues Impact Medication Safety

From July 1, 2023, through June 30, 2024, a total of 1,016 voluntarily submitted reports were sent to the ISMP National Medication Errors Reporting Program (ISMP MERP). Healthcare practitioners uti...

ISMP 27th Annual Cheers Awards: Making Medication Safety Magic

This week, ISMP celebrated the 27th annual CHEERS AWARDS, which recognize individuals, organizations, and groups that have demonstrated extraordinary commitment to advancing the science and study o...

Take Action to Prevent Tubing Misconnections—Part II

Problem: Tubing misconnections, or inappropriate connections between devices with different intended uses, have resulted in serious harm or death.1,2 In Part I, published in our October 31, 2024 ne...

Fluid shortage update—Safeguard imported products

Baxter announced it plans to restart manufacturing intravenous (IV) solutions at its North Cove, North Carolina facility this week. In the interim, as most readers are aware, the US Food and Drug A...

Survey Results Reveal Tubing Misconnections Are Common and Underreported—Part I

Problem: Tubing misconnections refer to what happens when a tube, syringe, or medical device from one delivery system is inappropriately connected to a system that serves a completely different fun...

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...

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...

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...