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

Newspaper/Magazine Article

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

February 10, 2021

ISMP Medication Safety Alert! Acute care edition. January 27, 2021;26(2).

Medication safety is challenged by both persistent problems and emerging situations. This article summarizes reports of errors submitted voluntarily to the Institute for Safe Medication Practices (ISMP) in 2020. The set list includes both pandemic-related hazards and common problems such as use of abbreviations and opioid-naïve patient prescribing.

Free full text

Related Resources From the Same Author(s)

Start the year off right by addressing these top 10 medication safety concerns from 2021.

February 9, 2022

Learning from errors with the new COVID-19 vaccines.

January 27, 2021

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

July 17, 2013

Still outside the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.

April 16, 2014

ISMP Canada identifies themes associated with fatal medication events in the home.

March 12, 2014

There's more to the 60 Minutes story on heparin errors.

April 9, 2008

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

September 30, 2020

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

January 29, 2020

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

August 9, 2023

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

February 8, 2023

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

July 14, 2021

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

September 8, 2021

More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.

May 19, 2021

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

May 12, 2021

A recurring call to action: every healthcare organization needs a medication safety officer!

March 10, 2021

Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.

March 3, 2021

Challenges with requiring five characters during ADC drug searches via override.

November 3, 2021

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

October 20, 2021

Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs.

August 11, 2021

Disrespectful behavior in healthcare: has it improved? Please take our survey!

October 21, 2021

Prevent errors during emergency use of hypertonic sodium chloride solutions.

November 17, 2021

Administration of concentrated potassium chloride for injection during a code: still deadly!

June 30, 2021

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

August 15, 2007

Double key bounce and double keying errors.

January 31, 2006

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

February 6, 2008

The five rights: a destination without a map.

February 7, 2007

Survey shows room for improvement with three new best practices for hospitals.

May 18, 2022

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

April 20, 2022

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

February 23, 2022

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

September 8, 2010

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

August 8, 2012

Students have a key role in a culture of safety: analysis of student-associated medication incidents.

August 8, 2018

Fatal outcome after inadvertent injection of topical epinephrine.

April 8, 2009

Inattentional blindness: what captures your attention?

March 11, 2009

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

January 26, 2011

Survey shows recession has weakened patient safety net.

January 27, 2010

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

January 23, 2019

Drug shortages continue to compromise patient care.

January 24, 2018

Technology and error-prevention strategies: why are we still overlooking the IV room?

January 28, 2015

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

February 1, 2023

Anticoagulant safety takes center stage in 2007.

January 24, 2007

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

December 7, 2022

Survey results from pharmacists provide support to enhance the organizational response to codes.

October 26, 2022

Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime.

September 7, 2022

Medication orders with future start dates: how far away is too far?

July 27, 2022

Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.

June 15, 2022

Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.

June 1, 2022

Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges.

March 24, 2021

Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II.

March 15, 2022

Medical abbreviations that have contradictory or ambiguous meanings.

February 12, 2020

Adverse glycemic events and critical emergencies.

December 15, 2021

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

April 8, 2015

Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.

February 24, 2016

A mislabeling event with batched drugs: the unintended consequences of practice changes.

February 19, 2014

November 14, 2007

What's in a name? Newborn naming conventions and wrong-patient errors.

May 8, 2019

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

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

Fatal misadministration of IV vincristine.

December 14, 2005

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

May 30, 2007

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

April 4, 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

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

March 26, 2008

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

Reducing patient harm from opiates.

March 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

Prevent administration of ear drops into the eyes.

December 14, 2022

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

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

November 4, 2009

Preventing medication errors during codes.

February 23, 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

Drug shortages threaten patient safety.

August 11, 2010

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

April 21, 2010

Preventing catheter/tubing misconnections: much needed help is on the way.

August 4, 2010

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

July 14, 2010

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

May 5, 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

Related Resources

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

February 29, 2024

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

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

Medical abbreviations that have contradictory or ambiguous meanings.

February 12, 2020

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

December 4, 2019

Medication errors: the year in review.

October 23, 2019

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

Standardising the classification of harm associated with medication errors: the Harm Associated with Medication Error Classification (HAMEC).

May 15, 2019

March 27, 2019

Medicine Safety: Take Care.

February 27, 2019

Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.

December 19, 2018

A prescription for enhancing electronic prescribing safety.

December 12, 2018

Detection of potential look-alike/sound-alike medication errors using Veterans Affairs administrative databases.

November 28, 2018

2 MSO programs show value of safety position.

November 21, 2018

Themed Issue on Innovations in Medication Safety.

August 22, 2018

Strategies for optimizing OR drug safety.

April 4, 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

Prescribing errors that cause harm.

October 5, 2016

"Use as directed" can cause confusion for both patients and practitioners.

September 14, 2016

The problem with medication reconciliation.

August 31, 2016

Standardization of compounded oral liquids for pediatric patients in Michigan.

August 31, 2016

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

June 8, 2016

Standardize 4 Safety.

May 25, 2016

Medication safety systems and the important role of pharmacists.

April 27, 2016

Evaluation of parenteral nutrition errors in an era of drug shortages.

December 16, 2015

Seven (potentially) deadly prescribing errors.

November 11, 2015

Hospice diagnosis: polypharmacy—a teachable moment.

October 7, 2015

See More About The Topic

Pharmacists

Quality and Safety Professionals

Medicine

Pharmacy

Medication Safety

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

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

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