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Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

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

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

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

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ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5.

Concentrated potassium chloride is a high-alert medication for which dosing errors are particularly injurious. This article shares the root causes of IV-push missteps with this medication during a code. Recommendations for improvement shared center on team characteristics and communication.

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

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ISMP Medication Safety Alert! Acute care edition. February 11, 2021;26(3):1-4.

Packaging and labeling problems hinder safe medication use. This article discusses label appearance and information design as distinct factors that affect the safe use of premixed large volume intravenous solutions.

Hidden medication loss when using a primary administration set for small-volume intermittent infusions.

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ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).

Infusion misadministration is not always immediately evident. This story illustrates the problem of underdosing during infusions and suggests that unclear policies and lack of problem awareness contribute to the persistence of the mistake. The piece recommends education, use of data, and storytelling as tactics to reduce underdosing.

Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns.

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ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.

Safety professionals encourage learning from errors to enhance the safe use of new processes and products. This article reviews vaccine error experiences and provides insight for the implementation of the COVID vaccine to help practitioners plan and activate safe vaccination processes.

Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB).

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ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4

In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom highlight the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.

Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose.

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ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9).

Lack of familiarity with smart pumps can lead to user error and patient harm. The article describes conditions that lead to a programing mistake. It suggests enhanced “hands on” education, improved medication labeling, required engagement with drug libraries when programing pumps and assessed equipment competency as actions to mitigate similar incident occurrence.

Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada.

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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.

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