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...

Medication Safety Issues with Newly Authorized PAXLOVID

On December 22, 2021, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for PAXLOVID, consisting of oral tablets of nirmatrelvir that are co-packaged with oral t...

Age-Related COVID-19 Vaccine Mix-Ups

Ever since the US Food and Drug Administration (FDA) authorized the emergency use of a specific formulation (10 mcg/0.2 mL) of the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine for ch...

Additional Strategies to Improve Complete Delivery of Small-Volume Intermittent Infusions

In the December 3, 2020 newsletter, ISMP published an article to remind practitioners that up to half of the medication in a 50 mL small-volume intermittent infusion (medication diluted in a small ...

A Recurring Call to Action: Every Healthcare Organization Needs a Medication Safety Officer!

Medication safety is a serious responsibility that is vital to the sustainability of healthcare organizations.1 On average, hospitalized patients experience one medication error each day,2,3 and pr...

Hidden Medication Loss When Using a Primary Administration Set for Small-Volume Intermittent Infusions

While covering for a colleague during patient rounds in an adult medical unit, a pharmacist noticed two empty 50 mL minibags of ZOSYN (piperacillin and tazobactam) hanging on a patient’s intravenou...