Call to Action: Practitioners Need to Warn Patients About Purchasing Counterfeit Drugs Online

Problem: Practitioners should be on guard for patients who may present to different healthcare settings with adverse reactions after knowingly or unknowingly taking substandard and falsified (SF) d...

Do You Know What Is Going on in Your OR? The Anesthesiology Residents' Perspective

PROBLEM: If you interviewed members of your perioperative team to ask what keeps them up at night, you might be surprised by what you uncover. The operating room (OR) represents an area with high p...

What’s in a Name?

The “-grastim” drug stem name Medications that end with the suffix “-grastim” belong to a class of medications known as granulocyte colony-stimulating factors (G-CSF). This class of medications bel...

Implement Strategies to Prevent Persistent Medication Errors and Hazards: 2025

Reflecting on events that occurred in 2024, we have identified four concerns related to medication safety, which were included in ECRI’s Top 10 Patient Safety Concerns for 2025 or ECRI’s Top 10 Hea...

Action Needed to Address Risk With Custom and Multi-Chamber Bag Parenteral Nutrition—Part II

PROBLEM: The complexity of parenteral nutrition (PN) coupled with the heightened risk of causing significant patient harm when used in error, calls for targeted safeguards throughout the medication...

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...