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...

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...

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 ...

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...

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...

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...

Criminalization of Human Error and a Guilty Verdict: A Travesty of Justice that Threatens Patient Safety

On March 25, 2022, most of the healthcare community were shocked and dismayed after learning that RaDonda Vaught had been convicted of criminally negligent homicide and gross neglect of an impaired...

Addressing Disrespectful Behaviors and Creating a Respectful, Healthy Workplace–Part II

In late 2021, ISMP conducted a survey on disrespectful behaviors in healthcare. Any behavior that discourages the willingness of staff or patients to speak up or interact with an individual because...

Survey Suggests Disrespectful Behaviors Persist in Healthcare: Practitioners Speak Up (Yet Again) – Part I

In our September 9, 2021 newsletter, we discussed the topic of disrespectful behaviors, which have persisted in healthcare for years. Unfortunately, too many remain silent or make excuses in an att...