Dangerous Wrong-Route Errors with Tranexamic Acid

We recently learned about three cases of accidental spinal injection of tranexamic acid instead of a local anesthetic intended for regional (spinal) anesthesia. Container mix-ups were involved in e...

The Differences Between Human Error, At-Risk Behavior, and Reckless Behavior Are Key to a Just Culture

Do you believe your organization operates within a Just Culture? We have asked this question many times while working collaboratively with healthcare organizations and professionals. It is not an e...

Speaking Up About Patient Safety Requires an Observant Questioner and a High Index of Suspicion

Healthcare practitioners are expected to speak up about patient safety concerns to help intercept errors and avoid adverse patient outcomes. By ‘speaking up,’ we mean raising concerns for the benef...

Independent Double Checks: Worth the Effort if Used Judiciously and Properly

Manual independent double checks of certain high-alert medications have been widely promoted in healthcare to help detect potentially harmful errors before they reach patients.1,2 Many practitioner...

Dangerous Wrong-Route Errors with Tranexamic Acid—A Major Cause for Concern

Problem: Earlier this month, we were notified about two cases of accidental intraspinal injection of tranexamic acid, occurring in two different states. Unfortunately, the report was sent anonymous...

Mix-ups Between Epidural Analgesia and IV Antibiotics in Labor and Delivery Units Continue to Cause Harm

Problem: Within weeks of each other, two hospitals have reported mix-ups between epidural analgesia and intravenous (IV) antibiotics in labor and delivery (L&D) units. These mix-ups mimic previ...

Check for Proper Nucala Dose Preparation

If you are using NUCALA (mepolizumab) for patients who have eosinophilic asthma, please check to ensure the correct volume is being dispensed. In a Safety Brief in our June 28, 2018 newsletter, we ...

Severe Under Dosing of Insulin With U-500 Pen

An emergency department (ED) pharmacist was talking to a patient about his U-500 insulin dose. The patient, who had been using a U-500 insulin pen, told the pharmacist that his dose was 75 units b...

Severe Hyperglycemia in Patients Incorrectly Using Insulin Pens at Home

The Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (MERP) has received several reports of patients who failed to remove the inner cover of a standard in...

Using Information From External Errors to Signal a “Clear and Present Danger”

Chances are you’ve scanned the headlines and read many of the stories about medication errors published in the ISMP Medication Safety Alert!, particularly the tragic errors. Just a few examples of ...

Reporting and Second-Order Problem Solving Can Turn Short-Term Fixes into Long-Term Remedies

Problem: Healthcare practitioners are repeatedly challenged by unexpected problems they encounter due to both large and small work system failures that hinder patient care. A medication needed for ...

Selected Medication Safety Risks to Manage in 2016 That Might Otherwise Fall Off the Radar Screen—Part II

Some medication safety risks are painfully apparent in an organization, while many others lie dormant in the system until an error or adverse event draws attention to them. We thought it would be u...