ISMP Medication Safety Alert® Acute Care Edition.

Newsletter/Journal

ISMP Medication Safety Alert® Acute Care Edition.

April 3, 2005

Plymouth Meeting, PA; Institute for Safe Medication Practices. ISSN 1550-6312.

The Institute for Safe Medication Practices' (ISMP) signature bi-weekly newsletter recounts actual experiences with medication errors reported to the ISMP. Feature articles here also present thoughtful reviews of error reduction strategies. Portions of the newsletter are available at no cost via the ISMP website.

Information

Related Resources From the Same Author(s)

ISMP Medication Safety Alert. Community/Ambulatory Care Edition.

April 3, 2005

Consumer Safe Medicine.

March 6, 2005

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

January 26, 2023

ISMP Medication Safety Alert!® Nurse-Advise ERR.

March 6, 2005

ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology.

May 4, 2022

ISMP Survey on High-Alert Medications in Acute Care Settings.

September 11, 2023

Targeted Medication Safety Best Practices for Hospitals.

February 22, 2024

ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.

August 24, 2022

Deep Dive: Racial and Ethnic Disparities in Health and Healthcare.

November 16, 2022

Consumermedsafety.org

September 8, 2022

ISMP Long-Term Care Advise-ERR.

July 24, 2013

Deep Dive: Safe Ambulatory Care, Strategies for Patient Safety & Risk Reduction.

November 13, 2019

ISMP's List of High-Alert Medications in Acute Care Settings.

January 14, 2024

Partnership for Health IT Patient Safety.

August 22, 2018

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

March 4, 2020

Safe Practices for Drug Allergies—Using CDS and Health IT.

August 7, 2019

Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization.

March 10, 2021

Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care.

February 17, 2021

Implementing Closing the Loop. Safe Practices for Diagnostic Results

February 5, 2020

ISMP's List of Confused Drug Names.

July 26, 2023

ISMP QuarterWatch Reports.

January 28, 2009

ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations.

April 17, 2024

Top 10 Patient Safety Concerns.

March 12, 2024

Health IT Safe Practices. Toolkit for the Safe Use of Copy and Paste.

March 23, 2016

Health IT Safe Practices for Closing the Loop.

August 22, 2018

The Institute for Safe Medication Practices.

September 7, 2005

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

Disrespectful behavior in your workplace.

April 13, 2022

Judy Smetzer Just Culture Champion Scholarships.

August 16, 2023

Fellowships and Mentorships Program.

February 8, 2023

ISMP Cheers Awards.

November 20, 2023

ISMP Survey on Verbal Orders.

January 25, 2017

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

February 29, 2024

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

Critical Care Safety: Essentials for ICU Patient Care and Technology.

August 8, 2007

Medication safety issues with newly authorized PAXLOVID.

January 12, 2022

Medication Safety Certificate Program.

August 24, 2022

Draft Guidelines for the Safe Communication of Electronic Medication Information.

September 16, 2015

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

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 Optimizing Safe Subcutaneous Insulin Use in Adults.

June 7, 2017

Guidelines for Adult IV Push Medications.

February 11, 2015

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

April 19, 2023

2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals.

May 11, 2017

Smart Healthcare Safety.

October 4, 2023

2012 ISMP International Medication Safety Self Assessment for Oncology.

April 18, 2012

ISMP Medication Safety Intensive.

April 12, 2024 - April 19, 2024

ISMP Medication Safety Self Assessment® for Perioperative Settings.

January 25, 2022

ISMP Medication Errors Reporting Program.

November 30, 2005

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

How to Prevent Medication Errors.

March 6, 2005

Dangerous wrong-route errors with tranexamic acid.

September 30, 2020

SafeMedicationUse.ca.

July 28, 2010

Oral Dosage Forms that Should Not Be Crushed.

December 6, 2006

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

Fluorouracil Incident Root Cause Analysis Report.

June 6, 2007

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

May 6, 2022 - May 6, 2022

Looking Collectively at Risk.

March 6, 2005

Medication error reporting and the work environment in a military setting.

July 22, 2009

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

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

EPINEPHrine pre-filled syringe shortage.

June 30, 2010

Patient Safety.

September 25, 2019

Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices.

August 24, 2022

Journal of Patient Safety.

May 11, 2005

One & Only Campaign.

March 2, 2011

Hospital Report Card: Ontario 2009.

April 8, 2009

Exploring nurses' attitudes, skills, and beliefs of medication safety practices.

August 24, 2022

ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical services and workforce-2021.

October 19, 2022

Regional variations in diagnostic practices.

May 12, 2010

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices.

October 28, 2020

Related Resources

ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations.

April 17, 2024

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

WebM&M Cases

The Impact of Communication on Medication Errors

March 15, 2021

WebM&M Cases

Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression

May 27, 2020

WebM&M Cases

Discharged with IV antibiotics: When issues arise, who manages the complications?

February 26, 2020

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

December 4, 2019

WebM&M Cases

Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation

November 27, 2019

Development of a standardized, citywide process for managing smart-pump drug libraries.

August 1, 2018

Journal of Patient Safety and Risk Management.

June 20, 2018

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

September 14, 2016

The problem with medication reconciliation.

August 31, 2016

The Feasibility of Determining the Effectiveness and Cost-effectiveness of Medication Organisation Devices Compared with Usual Care for Older People in a Community Setting: Systematic Review, Stakeholder Focus Groups and Feasibility RCT.

August 10, 2016

Incorporating indications into medication ordering—time to enter the age of reason.

August 10, 2016

Medication safety in neonatal care: a review of medication errors among neonates.

July 20, 2016

Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility.

July 13, 2016

Medication sharing, storage, and disposal practices for opioid medications among US adults.

June 22, 2016

Computerized dose range checking using hard and soft stop alerts reduces prescribing errors in a pediatric intensive care unit.

November 19, 2014

Out-of-hospital medication errors among young children in the United States, 2002–2012.

October 29, 2014

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

September 24, 2014

How useful are medication patient information leaflets to older adults? A content, readability and layout analysis.

September 17, 2014

Indication alerts intercept drug name confusion errors during computerized entry of medication orders.

September 3, 2014

Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation.

August 13, 2014

Medication Safety Officer's Handbook.

July 23, 2014

Look alike/sound alike drugs: a literature review on causes and solutions.

June 11, 2014

The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study.

April 2, 2014

Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation.

February 26, 2014

Improvement of medication event interventions through use of an electronic database.

December 18, 2013

Effect of barcode-assisted medication administration on emergency department medication errors.

October 2, 2013

Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients.

September 25, 2013

Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements.

September 4, 2013

See More About The Topic

ISMP Medication Safety Alert® Acute Care Edition.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

ISMP Medication Safety Alert® Acute Care Edition.

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