The PSNet Collection

ISMP Medication Safety Self Assessment® for Perioperative Settings.

Save to Library

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm.

Prevent errors during emergency use of hypertonic sodium chloride solutions.

Save to Library

ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.

Delays in diagnosis and treatment during life-threatening emergencies such as strokes can result in irreversible patient harm. This article discusses a variety of factors contributing to errors in administering hypertonic sodium chloride in emergent situations. The piece shares recommendations touching on various elements of the medication delivery process to enhance safety.

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

Save to Library

ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.

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

Save to Library

ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.

High-alert medication misadministration is of great concern due to the increased opportunity for harm associated with mistakes. This case describes how tubing and alarm management errors came together to result in the death of patient sedated with fentanyl.

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

Save to Library

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.

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

Save to Library

ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6.

Skin patches are a convenient medication delivery method but may harbor unique threats to safety. This article examines transdermal patch errors submitted to a national reporting program to provide safety improvement insights. Recommendations suggested for improvement focus on topics such as prescribing, patch management upon hospital admission, and labeling issues.

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

Save to Library

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.

COVID-19 Content. ISMP Medication Safety Alert!

Save to Library

March 2020--January 2021.

Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to reduce risks associated with distinct areas of the medication use process. The topics discuss areas that require specific attention during the COVID-19 pandemic such as the use of smart pumps and automated dispensing cabinets.

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

Save to Library

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.

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

Save to Library

ISMP Medication Safety Alert! Acute care edition. November 5, 2020; 25(22).

Mistakes in the intravenous medication preparation process can result in patient harm. This article summarizes the results of a national survey on preparation of sterile, injectable medications or infusions in the ambulatory setting. Safety issues documented include time pressures, lack of staff training, and unreliable adherence to standards.

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

Save to Library

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.

Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States.

Save to Library

Institute for Safe Medication Practices and US Food and Drug Administration Division of Drug Information. June 23, 2020.

The COVID-19 pandemic response is creating a need for care delivery adjustments that include changes in pharmacy and medication practices. This webinar discussed process alterations that have the potential to impact safe medication administration and provide context for the changes to help ensure they are effectively implemented.

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

Save to Library

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.

Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS.

Save to Library

ISMP Medication Safety Alert! Acute Care Edition. 2020;25.

Dose error-reduction systems (DERS) are standard functions in smart pumps. While they are designed to recognize dosing and programming errors, it has been observed that DERS are not fully utilized in operating rooms (OR). This article shares recommendations for addressing this medication safety gap including working with anesthesia providers and OR team members to establish use of DERS as an expected practice.

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

Save to Library

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.

ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps.

Save to Library

Institute for Safe Medication Practices. Horsham, PA: Institute for Safe Medication Practices; 2020.

Smart pumps are widely available as a medication safety tool yet there are challenges affecting their reliable use. This guideline expands on earlier recommendations to support smart pump use in both hospitals and the ambulatory setting. The material provides recommendations that address infrastructure, drug libraries, quality improvement data, workflow and electronic health record interoperability concerns.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users