Results of our survey on drug storage, stability, compatibility, and beyond use dating.

Newspaper/Magazine Article

Results of our survey on drug storage, stability, compatibility, and beyond use dating.

April 4, 2012

ISMP Medication Safety Alert! Acute care edition. March 22, 2012;17:1-4.

Reporting results of a survey about storage and disposal of medications, this newsletter article highlights how manufacturers' directions and evidence-based guidelines may differ markedly.

Free full text

Related Resources From the Same Author(s)

Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.

February 22, 2012

Sterile compounding tragedy is a symptom of a broken system on many levels.

October 31, 2012

Prescription drug time guarantees and their impact on patient safety in community pharmacies.

September 19, 2012

Just Culture and its critical link to patient safety—part 1 and part 2.

July 25, 2012

If safety is your yardstick, measuring culture from the top down must be a priority.

April 4, 2007

Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.

March 21, 2012

Reducing patient harm from opiates.

March 7, 2007

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

November 4, 2009

Building patient safety skills: common pitfalls when conducting a root cause analysis.

May 5, 2010

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

October 5, 2011

Safety with nebulized medications requires an interdisciplinary team approach.

March 7, 2018

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

May 12, 2021

Smart pump custom concentrations without hard "low concentration" alerts.

March 14, 2012

Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections.

October 3, 2012

Raising the index of suspicion: red flags that represent credible threats to patient safety.

August 8, 2012

A shortage of everything except errors: harm associated with drug shortages.

May 2, 2012

Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes.

April 12, 2017

Administering just the diluent or one of two vaccine components leaves patients unprotected.

June 4, 2014

Paralyzed by mistakes: preventing errors with neuromuscular blocking agents.

October 5, 2005

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

ADC survey shows some improvements, but unnecessary risks still exist.

February 6, 2008

Resolving human conflicts when questions about the safety of medical orders arise.

March 26, 2008

Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts?

June 3, 2020

Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?

December 19, 2012

Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.

November 28, 2012

Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.

July 18, 2012

Is an indication-based prescribing system in our future?

November 30, 2016

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

With oral chemotherapy, we simply must do better!

July 30, 2014

Heparin errors continue despite prior, high-profile, fatal events.

August 6, 2008

Maximize benefits of IV workflow management systems by addressing workarounds and errors.

September 20, 2017

ISMP survey shows provider text messaging often runs afoul of patient safety.

November 29, 2017

Unreadable barcodes and multiple barcodes on packages can lead to errors.

November 8, 2017

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

May 31, 2017

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

Using information from external errors to signal a "clear and present danger."

March 8, 2017

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

March 23, 2011

Do not let "Depo-" medications be a depot for mistakes.

April 13, 2016

Fatal outcome after inadvertent injection of topical epinephrine.

April 8, 2009

Beware of basal opioid infusions with PCA therapy.

March 25, 2009

Preventing errors when preparing and administering medications via enteral feeding tubes.

December 7, 2022

During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes.

September 30, 2020

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

September 8, 2021

ISMP Survey provides insights into preparation and admixture practices OUTSIDE the pharmacy.

November 18, 2020

Mail service and community pharmacies must work in tandem.

November 30, 2005

Prevent errors during emergency use of hypertonic sodium chloride solutions.

November 17, 2021

Survey results: community liaison programs to decrease hospital readmissions.

March 20, 2013

November 14, 2007

Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2.

April 8, 2015

Disrespectful behavior in healthcare...have we made any progress in the last decade?

July 17, 2013

A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!

December 4, 2019

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

Building a case for medication reconciliation.

May 3, 2006

IV potassium given epidurally: getting to the "route" of the problem.

April 19, 2006

Safety requires a state of mindfulness.

March 22, 2006

IV vincristine survey shows safety improvements needed.

March 8, 2006

Pharmaceutical industry and medical device companies: part of the solution?

November 29, 2006

Harmful errors: how will your facility respond?

October 18, 2006

Double key bounce and double keying errors.

January 31, 2006

Fatal misadministration of IV vincristine.

December 14, 2005

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

August 15, 2007

Fluorouracil error ends tragically, but application of lessons learned will save lives.

October 3, 2007

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

Error-prone conditions that lead to student nurse-related errors.

October 31, 2007

Potassium may no longer be stocked on patient care units, but serious threats still exist!

October 17, 2007

USA Today news series: clarifying the issues and embracing community pharmacy safety.

March 12, 2008

Keeping patients safe from iatrogenic methadone overdoses.

February 27, 2008

The five rights: a destination without a map.

February 7, 2007

Your attention please... designing effective warnings.

September 6, 2006

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

July 26, 2006

Rapid response team activation by patients can mitigate errors.

June 21, 2006

High-reliability organizations (HROs): what they know that we don't (Part I).

July 27, 2005

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

Loud wake-up call: unlabeled containers lead to patient’s death.

March 27, 2005

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

March 6, 2005

Please don't sleep through this wake-up call.

March 27, 2005

Eric Cropp weighs in on the error that sent him to prison.

December 16, 2009

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Preventing medication errors during codes.

February 23, 2011

Guidelines for timely medication administration: response to the CMS "30-minute rule."

January 26, 2011

ISMP updates its list of drug name pairs with Tall man letters.

December 1, 2010

Drug shortages: national survey reveals high level of frustration, low level of safety.

October 6, 2010

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

September 8, 2010

Drug shortages threaten patient safety.

August 11, 2010

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

April 21, 2010

DTaP–Tdap mix-ups now affecting hundreds of patients.

July 14, 2010

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

August 31, 2011

Oral solid medication appearance should play a greater role in medication error prevention.

August 10, 2011

Too many abandon the "second victims" of medical errors.

July 27, 2011

Scanner beep only means the barcode has been scanned.

July 13, 2011

Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization.

June 29, 2011

Multiple latent failures align to allow a serious drug interaction to harm a patient.

May 18, 2011

Another tragic parenteral nutrition compounding error.

May 11, 2011

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

July 15, 2009

How has the current economy affected patient safety?

September 23, 2009

Accidental IV infusion of heparinized irrigation in the OR.

December 21, 2016

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

May 18, 2016

Related Resources

ISMP Medication Safety Intensive.

April 12, 2024 - April 19, 2024

ISMP Survey on the 2024-2025 Targeted Medication Safety Best Practices for Hospitals.

February 29, 2024

Understanding and preventing vaccination errors.

May 31, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

ISMP updates its list of drug names with tall man (mixed case) letters based on survey results.

February 8, 2023

ASHP Guidelines on Preventing Diversion of Controlled Substances.

December 14, 2022

Prevent administration of ear drops into the eyes.

December 14, 2022

ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology.

May 4, 2022

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

October 20, 2021

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

February 10, 2021

Key potentially inappropriate drugs in pediatrics: the KIDs list.

June 24, 2020

WebM&M Cases

The Lost Start Date: an Unknown Risk of E-prescribing

October 30, 2019

Ten ways to improve medication safety in community pharmacies.

August 7, 2019

How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions.

July 10, 2019

Medicine Safety: Take Care.

February 27, 2019

2 MSO programs show value of safety position.

November 21, 2018

Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention.

November 14, 2018

I-PASS checklist: a powerful tool for patient handoffs.

October 24, 2018

How to prevent the top 4 medication errors.

October 17, 2018

Preventing dispensing errors by alerting for drug confusions in the pharmacy information system—a survey of users.

August 8, 2018

Board of pharmacy practices related to medication errors and their potential impact on patient safety.

August 1, 2018

Necessity for a pathway for "high-alert" patients.

May 23, 2018

Promising roles for pharmacists in addressing the U.S. opioid crisis.

February 14, 2018

High-alert medications: the safeguards that you should put in place to reduce risks.

November 1, 2017

Errors originating in hospital and health-system outpatient pharmacies.

July 19, 2017

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

The effects of bar-coding technology on medication errors: a systematic literature review.

April 19, 2017

Expanded pharmacy technician roles: accepting verbal prescriptions and communicating prescription transfers.

February 1, 2017

Lost in translation: medication labeling for immigrant families.

December 21, 2016

See More About The Topic

Hospitals

Outpatient Pharmacy

Pharmacists

Quality and Safety Professionals

Pharmacy

Results of our survey on drug storage, stability, compatibility, and beyond use dating.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Results of our survey on drug storage, stability, compatibility, and beyond use dating.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site