Fact Sheet/FAQs How to Prevent Medication Errors. Citation Text: Institute for Safe Medication Practices; ISMP Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Institute for Safe Medication Practices; ISMP This booklet provides instructions, recommendations, and safe tips for patients in the hospital, at their doctor's office, or at home. Additional readings are included. Free full text (PDF) Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Institute for Safe Medication Practices; ISMP Copy Citation Related Resources From the Same Author(s) ISMP Survey on Drug Shortages. September 13, 2017 ISMP Follow-up Survey on Smart Pump Data Usage. March 21, 2018 ISMP Survey on the Common Use of Medication-related Metrics. May 13, 2015 ISMP Statement on Use of Metric Measurements to Prevent Errors with Oral Liquids. December 14, 2011 ISMP Survey on IV Push Medication Practices. August 15, 2018 ISMP Survey on Texting Medical Orders. July 19, 2017 ISMP Announces 10th Annual Cheers Awards Recipients. November 21, 2007 Oral Dosage Forms that Should Not Be Crushed. December 6, 2006 ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. March 4, 2020 ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. May 17, 2021 Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. March 23, 2016 ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. October 1, 2021 High-Alert Medication Learning Guides for Consumers. December 5, 2012 The Case for Medication Safety Officers (MSO). August 22, 2018 ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. December 5, 2018 ISMP Medication Safety Self Assessment for High-Alert Medications. October 4, 2017 10 Medication Safety Tips for Hospitalized Patients. September 25, 2019 Guidance for the Safe Use of Automated Dispensing Cabinets. May 7, 2019 2017 ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacy. March 6, 2005 FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters. January 26, 2023 ISMP's Guidelines for Standard Order Sets. March 31, 2010 2011 ISMP Medication Safety Self Assessment for Hospitals. May 4, 2011 ISMP Guidelines for Safe Electronic Communication of Medication Information. February 6, 2019 ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology. May 4, 2022 ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. June 7, 2017 ISMP Survey on High-Alert Medications in Acute Care Settings. September 11, 2023 Targeted Medication Safety Best Practices for Hospitals. February 22, 2024 Guidelines for Adult IV Push Medications. February 11, 2015 ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. August 24, 2022 2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals. May 11, 2017 ISMP Survey on Verbal Orders. January 25, 2017 Deep Dive: Racial and Ethnic Disparities in Health and Healthcare. November 16, 2022 ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. February 12, 2021 Consumermedsafety.org September 8, 2022 SafeMedicationUse.ca. July 28, 2010 2012 ISMP International Medication Safety Self Assessment for Oncology. April 18, 2012 Leading a Strategic Planning Effort. March 6, 2005 Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically. February 6, 2013 Institute for Safe Medication Practices International Mentorship Program. February 1, 2022 - March 8, 2022 ISMP National Vaccine Errors Reporting Program. December 18, 2013 ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. November 16, 2022 ISMP Medication Safety Self Assessment® for Perioperative Settings. January 25, 2022 Disrespectful behavior in your workplace. April 13, 2022 Judy Smetzer Just Culture Champion Scholarships. August 16, 2023 ISMP Medication Errors Reporting Program. November 30, 2005 Fellowships and Mentorships Program. February 8, 2023 ISMP Cheers Awards. November 20, 2023 EPINEPHrine pre-filled syringe shortage. June 30, 2010 Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. April 1, 2015 Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL. July 8, 2015 Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. June 13, 2018 Severe hyperglycemia in patients incorrectly using insulin pens at home. October 25, 2017 Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation. February 26, 2014 Age-related COVID-19 vaccine mix-ups. December 15, 2021 ISMP Long-Term Care Advise-ERR. July 24, 2013 ISMP Survey on the 2024-2025 Targeted Medication Safety Best Practices for Hospitals. February 29, 2024 ISMP QuarterWatch Reports. January 28, 2009 FDA/ISMP Safe Medication Management Fellowship Program. February 8, 2023 Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety. August 19, 2020 Diversion is a Threat to Patient Safety: Adopting Best Practices. April 6, 2022 - April 6, 2022 Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. October 26, 2021 - October 26, 2021 ISMP Medication Safety Alert!® Nurse-Advise ERR. March 6, 2005 Consumer Safe Medicine. March 6, 2005 ISMP's List of High-Alert Medications in Acute Care Settings. January 14, 2024 ISMP's List of Confused Drug Names. July 26, 2023 ISMP Targeted Medication Safety Best Practices for Community Pharmacy. April 19, 2023 Medication safety issues with newly authorized PAXLOVID. January 12, 2022 Medication Safety Certificate Program. August 24, 2022 Fluorouracil Incident Root Cause Analysis Report. June 6, 2007 Draft Guidelines for the Safe Communication of Electronic Medication Information. September 16, 2015 Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error. May 6, 2022 - May 6, 2022 ISMP Medication Safety Alert. Community/Ambulatory Care Edition. April 3, 2005 ISMP Medication Safety Alert® Acute Care Edition. April 3, 2005 Looking Collectively at Risk. March 6, 2005 Pathways for Patient Safety. February 11, 2009 Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States. June 23, 2020 ISMP Medication Safety Intensive. April 12, 2024 - April 19, 2024 Dangerous wrong-route errors with tranexamic acid. September 30, 2020 Mail service and community pharmacies must work in tandem. November 30, 2005 Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors. August 19, 2015 One & Only Campaign. March 2, 2011 Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices. August 24, 2022 Safetyleaders.org March 6, 2005 A Framework for Safe, Reliable, and Effective Care. February 15, 2017 A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing. June 8, 2011 Surfing the Healthcare Tsunami: Bring Your Best Board. May 16, 2012 A mislabeling event with batched drugs: the unintended consequences of practice changes. February 19, 2014 Patients with low health literacy make more errors interpreting instructions and warnings. December 13, 2023 Product-related issues make error potential enormous with investigational drugs. November 14, 2007 A safe practice standard for barcode technology. June 3, 2015 Disrespectful behavior in healthcare...have we made any progress in the last decade? July 17, 2013 What's in a name? Newborn naming conventions and wrong-patient errors. May 8, 2019 Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. March 24, 2021 Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023 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 View More Related Resources What Do You Do If You Think You Have Been Harmed By Your Healthcare. February 28, 2024 Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. July 12, 2023 Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals - a qualitative study. July 5, 2023 Towards safe conversational agents in healthcare. June 14, 2023 The impact of language barriers on patient care: a pharmacy perspective. May 24, 2023 Speak Up [brochures]. May 1, 2023 Preventing home medication errors. April 12, 2023 Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches. November 30, 2022 Accidental exposures to fentanyl patches continue to be deadly to children. July 21, 2021 Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. February 24, 2021 Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. November 4, 2020 FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. April 8, 2020 Sepsis Smart. October 30, 2019 Patient Safety. September 25, 2019 10 Medication Safety Tips for Hospitalized Patients. September 25, 2019 A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety. April 17, 2019 Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error. March 6, 2019 Visual acuity, literacy, and unintentional misuse of nonprescription medications. June 13, 2018 Association of health literacy with postoperative outcomes in patients undergoing major abdominal surgery. October 25, 2017 All consumer medication information is not created equal: implications for medication safety. April 19, 2017 Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites. April 19, 2017 Blood Thinner Pills: Your Guide to Using Them Safely. September 21, 2015 Consumer Guide to Adverse Health Events. February 28, 2015 Facilitating Patient Understanding of Discharge Instructions: Workshop Summary. December 17, 2014 FDA Pharmacists Help Consumers Use Medicines Safely. November 19, 2014 Implications of Health Literacy for Public Health: Workshop Summary. October 8, 2014 Four Medication Safety Tips for Older Adults. June 18, 2014 Medication Safety Program. June 11, 2014 Be an Active Member of Your Health Care Team. May 21, 2014 FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. October 9, 2013 View More See More About The Topic Patients Medication Safety Health Literacy Improvement Patient Education
ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology. May 4, 2022
Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically. February 6, 2013
Institute for Safe Medication Practices International Mentorship Program. February 1, 2022 - March 8, 2022
Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. April 1, 2015
Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL. July 8, 2015
Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. June 13, 2018
Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation. February 26, 2014
ISMP Survey on the 2024-2025 Targeted Medication Safety Best Practices for Hospitals. February 29, 2024
Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety. August 19, 2020
Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. October 26, 2021 - October 26, 2021
Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error. May 6, 2022 - May 6, 2022
Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States. June 23, 2020
Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors. August 19, 2015
Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices. August 24, 2022
A mislabeling event with batched drugs: the unintended consequences of practice changes. February 19, 2014
Patients with low health literacy make more errors interpreting instructions and warnings. December 13, 2023
Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. March 24, 2021
Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021
Patient death tied to lack of proper escalation process for barcode scanning failures. October 4, 2023
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
Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. July 12, 2023
Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals - a qualitative study. July 5, 2023
Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches. November 30, 2022
Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. February 24, 2021
Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. November 4, 2020
FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. April 8, 2020
A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety. April 17, 2019
Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error. March 6, 2019
Association of health literacy with postoperative outcomes in patients undergoing major abdominal surgery. October 25, 2017
All consumer medication information is not created equal: implications for medication safety. April 19, 2017
Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites. April 19, 2017
FDA requiring color changes to Duragesic (fentanyl) pain patches to aid safety―emphasizing that accidental exposure to used patches can cause death. October 9, 2013