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ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25(3):1-6.

Errors in IV medication use can result in serious adverse health consequences. This article shares an analysis of approximately 200 oxytocin incident reports. Five areas of concern identified include prescribing, look alike/sound alike packaging, preparation, administration and communication problems. Patient engagement, bar coding use and verbal order reduction are highlighted amongst the listed improvement strategies.