Fact Sheet/FAQs How to Prevent Medication Errors. Citation Text: Institute for Safe Medication Practices; ISMP Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Institute for Safe Medication Practices; ISMP This booklet provides instructions, recommendations, and safe tips for patients in the hospital, at their doctor's office, or at home. Additional readings are included. Free full text (PDF) Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Institute for Safe Medication Practices; ISMP Copy Citation Related Resources From the Same Author(s) ISMP Survey on Drug Shortages. September 13, 2017 ISMP Survey on the Common Use of Medication-related Metrics. May 13, 2015 SafeMedicationUse.ca. July 28, 2010 ISMP Statement on Use of Metric Measurements to Prevent Errors with Oral Liquids. December 14, 2011 ISMP Follow-up Survey on Smart Pump Data Usage. March 21, 2018 ISMP Survey on IV Push Medication Practices. August 15, 2018 ISMP Survey on Verbal Orders. January 25, 2017 ISMP Survey on Texting Medical Orders. July 19, 2017 ISMP Announces 10th Annual Cheers Awards Recipients. November 21, 2007 FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters. January 26, 2023 2012 ISMP International Medication Safety Self Assessment for Oncology. April 18, 2012 ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. March 4, 2020 Dangerous wrong-route errors with tranexamic acid. September 30, 2020 EPINEPHrine pre-filled syringe shortage. June 30, 2010 Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically. February 6, 2013 Oral Dosage Forms that Should Not Be Crushed. December 6, 2006 Medication safety issues with newly authorized PAXLOVID. January 12, 2022 10 Medication Safety Tips for Hospitalized Patients. September 25, 2019 Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety. August 19, 2020 ISMP Medication Safety Self Assessment® for Perioperative Settings. January 25, 2022 Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. October 26, 2021 - October 26, 2021 Age-related COVID-19 vaccine mix-ups. December 15, 2021 Disrespectful behavior in your workplace. April 13, 2022 Diversion is a Threat to Patient Safety: Adopting Best Practices. April 6, 2022 - April 6, 2022 ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. November 16, 2022 Deep Dive: Racial and Ethnic Disparities in Health and Healthcare. November 16, 2022 ISMP Survey on the 2024-2025 Targeted Medication Safety Best Practices for Hospitals. February 29, 2024 ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. August 24, 2022 Judy Smetzer Just Culture Champion Scholarships. August 16, 2023 Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error. May 6, 2022 - May 6, 2022 ISMP Targeted Medication Safety Best Practices for Community Pharmacy. April 19, 2023 Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States. June 23, 2020 ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. December 5, 2018 Draft Guidelines for the Safe Communication of Electronic Medication Information. September 16, 2015 Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection. April 1, 2015 Guidelines for Adult IV Push Medications. February 11, 2015 Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. March 23, 2016 Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL. July 8, 2015 ISMP Survey on High-Alert Medications in Acute Care Settings. September 11, 2023 ISMP Guidelines for Safe Electronic Communication of Medication Information. February 6, 2019 ISMP's Guidelines for Standard Order Sets. March 31, 2010 ISMP's List of Confused Drug Names. July 26, 2023 2011 ISMP Medication Safety Self Assessment for Hospitals. May 4, 2011 Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation. February 26, 2014 Targeted Medication Safety Best Practices for Hospitals. February 22, 2024 ISMP National Vaccine Errors Reporting Program. December 18, 2013 ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology. May 4, 2022 High-Alert Medication Learning Guides for Consumers. December 5, 2012 ISMP Long-Term Care Advise-ERR. July 24, 2013 ISMP List of High-Alert Medications in Community/Ambulatory Healthcare. October 1, 2021 ISMP Medication Safety Intensive. March 12, 2024 The Case for Medication Safety Officers (MSO). August 22, 2018 Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. June 13, 2018 Medication Safety Certificate Program. August 24, 2022 Severe hyperglycemia in patients incorrectly using insulin pens at home. October 25, 2017 ISMP Medication Safety Self Assessment for High-Alert Medications. October 4, 2017 ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. June 7, 2017 Institute for Safe Medication Practices International Mentorship Program. February 1, 2022 - March 8, 2022 FDA/ISMP Safe Medication Management Fellowship Program. February 8, 2023 ISMP QuarterWatch Reports. January 28, 2009 Pathways for Patient Safety. February 11, 2009 Consumermedsafety.org September 8, 2022 Fluorouracil Incident Root Cause Analysis Report. June 6, 2007 ISMP's List of High-Alert Medications in Acute Care Settings. January 14, 2024 Fellowships and Mentorships Program. February 8, 2023 Guidance for the Safe Use of Automated Dispensing Cabinets. May 7, 2019 2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals. May 11, 2017 ISMP Medication Safety Alert. Community/Ambulatory Care Edition. April 3, 2005 ISMP Medication Safety Alert® Acute Care Edition. April 3, 2005 ISMP Medication Errors Reporting Program. November 30, 2005 Leading a Strategic Planning Effort. March 6, 2005 2017 ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacy. March 6, 2005 Looking Collectively at Risk. March 6, 2005 ISMP Medication Safety Alert!® Nurse-Advise ERR. March 6, 2005 Consumer Safe Medicine. March 6, 2005 ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. April 17, 2024 ISMP Cheers Awards. November 20, 2023 ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. May 17, 2021 Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices. August 24, 2022 One & Only Campaign. March 2, 2011 Mail service and community pharmacies must work in tandem. November 30, 2005 A Framework for Safe, Reliable, and Effective Care. February 15, 2017 Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP. August 26, 2020 Quality standards for safe medication in nursing homes: development through a multistep approach including a Delphi consensus study. October 27, 2021 Patients and relatives as auditors of safe practices in oncology and hematology day hospitals. March 31, 2021 Association between Leapfrog safe practices score and hospital mortality in major surgery. November 30, 2011 A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies. January 25, 2023 Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors. August 19, 2015 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 Exploring nurses' attitudes, skills, and beliefs of medication safety practices. August 24, 2022 Adverse health events related to self-medication practices among elderly: a systematic review. May 31, 2017 Best practices in medication administration: preventing adverse drug events in perinatal settings. March 7, 2007 The effect of the fit between organizational culture and structure on medication errors in medical group practices. February 7, 2007 Engineering care transitions: clinician perceptions of barriers to safe medication management during transitions of patient care. May 19, 2021 Medication errors in pediatric anesthesia: a report from the Wake Up Safe quality improvement initiative. November 22, 2017 Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative. December 12, 2018 Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses. February 15, 2023 Hand Hygiene in Healthcare Settings. March 27, 2005 In situ simulation: an essential tool for safe preparedness for the COVID-19 pandemic. November 25, 2020 Responding to safe care: healthcare staff experiences caring for a child with intellectual disability in hospital. Implications for practice and training. May 11, 2022 View More Related Resources What Do You Do If You Think You Have Been Harmed By Your Healthcare. February 28, 2024 Five Medication Safety Tips for Older Adults. February 15, 2024 Health literacy-informed communication to reduce discharge medication errors in hospitalized children: a randomized clinical trial. January 31, 2024 Analysis of a medication safety intervention in the pediatric emergency department. January 24, 2024 Parents' understanding of medication at discharge and potential harm in children with medical complexity. December 20, 2023 Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. November 1, 2023 Patient Safety Primers Digital Health Literacy October 31, 2023 Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising. October 18, 2023 Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023. October 4, 2023 Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. July 12, 2023 Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals - a qualitative study. July 5, 2023 Towards safe conversational agents in healthcare. June 14, 2023 The impact of language barriers on patient care: a pharmacy perspective. May 24, 2023 Speak Up [brochures]. May 1, 2023 Preventing home medication errors. April 12, 2023 WebM&M Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022 Association of patient and family reports of hospital safety climate with language proficiency in the US. June 29, 2022 Accidental exposures to fentanyl patches continue to be deadly to children. July 21, 2021 Unite for Safe Care. September 17, 2021 - September 17, 2021 Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. February 24, 2021 Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. November 4, 2020 The impact of the COVID-19 pandemic on Emergency Department visits and patient safety in the United States. August 26, 2020 The safety of health care for ethnic minority patients: a systematic review. July 29, 2020 FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. April 8, 2020 Sepsis Smart. October 30, 2019 Patient Safety. September 25, 2019 10 Medication Safety Tips for Hospitalized Patients. September 25, 2019 The patient's role in patient safety. June 1, 2019 A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety. April 17, 2019 Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error. March 6, 2019 View More See More About The Topic Patients Medication Safety Health Literacy Improvement Patient Education
Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically. February 6, 2013
Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety. August 19, 2020
Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors. October 26, 2021 - October 26, 2021
ISMP Survey on the 2024-2025 Targeted Medication Safety Best Practices for Hospitals. February 29, 2024
Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error. May 6, 2022 - May 6, 2022
Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States. June 23, 2020
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
Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation. February 26, 2014
ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology. May 4, 2022
Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages. June 13, 2018
Institute for Safe Medication Practices International Mentorship Program. February 1, 2022 - March 8, 2022
Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices. August 24, 2022
Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP. August 26, 2020
Quality standards for safe medication in nursing homes: development through a multistep approach including a Delphi consensus study. October 27, 2021
Patients and relatives as auditors of safe practices in oncology and hematology day hospitals. March 31, 2021
Association between Leapfrog safe practices score and hospital mortality in major surgery. November 30, 2011
A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies. January 25, 2023
Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors. August 19, 2015
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
Adverse health events related to self-medication practices among elderly: a systematic review. May 31, 2017
Best practices in medication administration: preventing adverse drug events in perinatal settings. March 7, 2007
The effect of the fit between organizational culture and structure on medication errors in medical group practices. February 7, 2007
Engineering care transitions: clinician perceptions of barriers to safe medication management during transitions of patient care. May 19, 2021
Medication errors in pediatric anesthesia: a report from the Wake Up Safe quality improvement initiative. November 22, 2017
Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative. December 12, 2018
Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses. February 15, 2023
In situ simulation: an essential tool for safe preparedness for the COVID-19 pandemic. November 25, 2020
Responding to safe care: healthcare staff experiences caring for a child with intellectual disability in hospital. Implications for practice and training. May 11, 2022
Health literacy-informed communication to reduce discharge medication errors in hospitalized children: a randomized clinical trial. January 31, 2024
Parents' understanding of medication at discharge and potential harm in children with medical complexity. December 20, 2023
Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders. November 1, 2023
Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising. October 18, 2023
Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023. October 4, 2023
Caregiver and clinician perspectives on discharge medication counseling: a qualitative study. July 12, 2023
Patient safety and sense of security when telemonitoring chronic conditions at home: the views of patients and healthcare professionals - a qualitative study. July 5, 2023
WebM&M Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022
Association of patient and family reports of hospital safety climate with language proficiency in the US. June 29, 2022
Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. February 24, 2021
Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education. November 4, 2020
The impact of the COVID-19 pandemic on Emergency Department visits and patient safety in the United States. August 26, 2020
FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. April 8, 2020
A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety. April 17, 2019
Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error. March 6, 2019