Highlighted Articles

2/8/2018 Medication Errors During Insulin Administration for Patients with Hyperkalemia
1/25/2018 QuarterWatch (2 years of data ending June 2017) Safety signals for pharmaceutical contraceptives   
1/11/2018 Drug shortages continue to compromise patient care
12/14/2017 ISMP?CHEERS?AWARDS 20th Anniversary Celebrating the Heart & Soul of Medication Safety
11/30/2017 EHR-smart pump interoperability resulted in electronic documentation of different flow rates
11/16/2017 ISMP survey shows provider text messaging often runs afoul of patient safety
11/2/2017 QuarterWatch™ (2017 Quarter 1 Data) Safety signals for two novel drugs, Nuplazid and Entresto
10/19/2017 Unreadable barcodes and multiple barcodes on packages can lead to errors
10/5/2017 Alarming survey results from CDC: Unsafe injection practices continue
9/21/2017 ISMP launches the first high-alert medication safety self assessment for inpatient and outpatient facilities
9/7/2017 Maximize benefits of IV workflow management systems by addressing workarounds and errors
8/10/2017 FDA Advise-ERR Vyxeos: Verify drug name and dose to avoid errors!
8/24/2017 Telling true stories is an ISMP hallmark Here’s why you should tell stories, too…
8/11/2016 Low dose enteral syringe tip gets FDA clearance
8/10/2017 Multifactorial causes of tacrolimus errors: Confusion with strength/ formulation, look-alike names, preparation errors, and more
7/27/2017 QuarterWatch™ (2016 Annual Report) Part II: Oral anticoagulants—the nation’s top risk of acute injury from drugs
7/13/2017 QuarterWatch™ (2016 Annual Report) Part I: Consumers at risk from drug withdrawal symptoms
6/29/2017 The texting debate: Beneficial means of communication or safety and security risk?
6/15/2017 Death due to pharmacy compounding error reinforces need for safety focus
6/1/2017 Common missteps with medication safety: Rolling a single dice, ineffective strategies, and unexecuted action plans
5/18/2017 Despite technology, verbal orders persist, read back is not widespread, and errors continue
5/4/2017 Unrealized exposure to heparin leads to missed HIT diagnosis and subsequent limb thrombosis
4/20/2017 QuarterWatch (2016 Quarter 3 Data) Depression and suicidal behaviors: Exploring the link with certain drugs Serious injuries from aspirin
4/6/2017 Two unsafe practices: Administration of a product with a precipitate and reuse of a saline flush syringe
3/9/2017 Smoflipid-Intralipid look-alike
3/23/2017 Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes
3/9/2017 What’s in a generic name? Clues about the drug’s use and possible adverse effects
2/23/2017 DTaP, LAIV, MCV4, PPSV23, HZV, 9vHPV… Alphabet soup vaccine abbreviations and acronyms lead to errors
2/9/2017 Using information from external errors to signal a “clear and present danger”
1/26/2017 QuarterWatch™ (2016 Quarter 2 Data) Liver failure with hepatitis C drugs, drugs with signals for insomnia, and harm from antipsychotic drugs
1/12/2017 Concomitant use of Entresto and ACE inhibitors can lead to serious outcomes
1/12/2017 Accidental injection of topical thrombin continues
12/15/2016 Putting Our BOOTS ON to kick off the 19th Annual ISMP CHEERS Award
12/1/2016 Accidental IV infusion of heparinized irrigation in the OR
11/17/2016 Is an indication-based prescribing system in our future?
11/3/2016 Chloral hydrate: Is it still being used? Are there safer alternatives?
10/20/2016 Managing hospitalized patients with ambulatory pumps—Part 2 Guidelines for the use of insulin pumps during hospitalization
10/6/2016 QuarterWatch™ (2016 Quarter 1 Data) Lessons learned from withdrawal of the Zecuity patch Patient difficulties using the Tanzeum pen
9/22/2016 Worth Repeating… Recent PCA by proxy event suggests reassessment of practices that may have fallen by the wayside
9/22/2016 Volumetric dosing of EPINEPHrine for neonates could lead to dosing errors
9/8/2016 Understanding human over-reliance on technology
8/25/2016 “Use as directed” can cause confusion for both patients and practitioners
8/11/2016 What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers
7/28/2016 ISMP National Vaccine Errors Reporting Program One in three vaccine errors associated with age-related factors
7/14/2016 Correct use of inhalers: Help patients breathe easier
6/30/2016 QuarterWatch™ Annual Report Issue Trends and changes in 2015 that impact medication safety
6/16/2016 Paralyzed by mistakes Reassess the safety of neuromuscular blockers in your facility
6/2/2016 Special Edition: Tall Man Lettering ISMP updates its list of drug names with tall man letters
5/19/2016 Reporting and second-order problem solving can turn short-term fixes into long-term remedies
5/5/2016 Fifty Hospital Employees Given Insulin Instead of Influenza Vaccine
5/5/2016 Hardwiring safety into the computer system One hospital’s actions to provide technology support for U-500 insulin
12/4/2014 What else is stored in a refrigerator with influenza vaccine?
4/21/2016 Prescribing errors with levETIRAcetam oral solution
4/7/2016 QuarterWatch™ Latest Edition Cancer risks with biological products for psoriasis Sudden hearing loss with tadalafil and sildenafil
3/24/2016 Do not let “Depo-” medications be a depot for mistakes
3/10/2016 Partially filled vials and syringes in sharps containers are a key source of drugs for diversion
2/25/2016 Government and industry fail to protect the public when they suggest “carefully following instructions” is enough to prevent vaccine errors
2/11/2016 Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—Part II
1/28/2016 Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—Part I
1/14/2016 QuarterWatch™ 2015 Quarter 1 and 2 Report: Focus on a new sleep medication, changing opioid use, and new diabetes medications
12/17/2015 ENFit update
12/17/2015 18th Annual ISMP CHEERS Awards Looking into the Future for Medication Safety
12/3/2015 Dispelling a few myths about ISMP
11/19/2015 Managing hospitalized patients with ambulatory pumps: Findings from an ISMP survey–Part 1
11/5/2015 Warning: Don’t confuse idarucizumab with IDArubicin
11/5/2015 Key vulnerabilities in the surgical environment: Container mix-ups and syringe swaps
10/22/2015 Trissel had it right: Re-emphasis on pharmaceutics testing needed
10/8/2015 Severe harm and death associated with errors and drug interactions involving low-dose methotrexate
9/24/2015 FDA Advise-ERR Avoid using the error-prone abbreviation, TPA
9/24/2015 QuarterWatch™ 2014 Annual Report Signals for TNF blocking agents, anticoagulants, Lipitor, growth hormone
9/10/2015 Ambulatory pump safety: Managing home infusion patients admitted to the ED and hospital
8/27/2015 ISMP comments on BD syringe potency issue
8/27/2015 Draft Guidelines for the Safe Communication of Electronic Medication Information
8/13/2015 A successful ENFit launch still won’t stop all incidents of oral medications given intravenously
7/30/2015 Update on implementation of the new ENFit enteral connectors
7/16/2015 FDA Advise-ERR Mefloquine—Not the same as Malarone!
7/2/2015 Results of pediatric medication safety survey (Part 2) Comparing data subsets points out areas for improvement
6/18/2015 Accidental overdoses involving fluorouracil infusions
6/4/2015 Part 1: Results of Survey on Pediatric Medication Safety More is needed to protect hospitalized children from medication errors
5/21/2015 The absence of a drug-disease interaction alert leads to a child’s death
5/7/2015 QuarterWatch™ 2014 Quarter 2 Zolpidem and canagliflozin safety signals, thousands of incomplete rosiglitazone reports
4/23/2015 Life-threatening errors with flecainide suspension in children
4/9/2015 South Carolina medication error bill is dangerously off target
4/9/2015 ENFit enteral devices are on their way...Important safety considerations for hospitals
3/26/2015 Recommendations for practitioners to prevent vaccine errors Part 2: Analysis of ISMP Vaccine Errors Reporting Program (VERP)
3/12/2015 Delayed administration and contraindicated drugs place hospitalized Parkinson’s disease patients at risk
2/26/2015 EPINEPHrine for anaphylaxis: Autoinjector or 1 mg vial or ampul?
2/12/2015 Getting closer to the bull’s eye: 2014-2015 Targeted Medication Safety Best Practices (Follow-up survey results)
1/29/2015 QuarterWatch™ (Special Report): A critique of FDA’s key drug safety reporting system  
1/15/2015 Hazard Alert: Demonstration IV solutions administered to patients
1/15/2015 Technology and error-prevention strategies: Why are we still overlooking the IV room?
12/18/2014 Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals
12/4/2014 What else is stored in a refrigerator with influenza vaccine?
12/4/2014 Confusion abounds! 2-year summary of the ISMP National Vaccine Errors Reporting Program (Part I)
11/20/2014 Unverified patient-reported error: A false alarm can have real consequences
11/6/2014 Strengthen your resolve: No unlabeled containers anywhere, ever!
10/23/2014 A crack in our best armor: “Wrong patient” insulin pen injections alarmingly frequent even with barcode scanning
10/9/2014 The “Dirty Dozen” 12 persistent safety gaffes that we need to resolve!
9/25/2014 Quarterwatch™ Report (Quarters 2 and 3, 2013): Signals for Chantix, Xyrem, Gilenya, and Tecfidera  
8/14/2014 New "Imaging Bulk Package" For Use With Power Injectors
9/11/2014 Be wary of “misspeakers” who “shoot from the hip”
8/28/2014 VARIZIG dilution problems reported
8/14/2014 URGENT! Health systems need to plan NOW for upcoming changes in enteral feeding device connectors
7/31/2014 Safety requires a state of mindfulness
7/17/2014 With oral chemotherapy, we simply must do better!
7/3/2014 Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications
6/19/2014 Some IV medications are diluted unnecessarily in patient care areas, creating undue risk
6/5/2014 Misidentification of alphanumeric symbols
5/22/2014 Administering just the diluent or one of two vaccine components leaves patients unprotected
5/8/2014 QuarterWatch ™ Drug hypersensitivity reactions  Allergic reactions second most frequently reported serious event
4/24/2014 Part II: Disrespectful behaviors Their impact, why they arise and persist, and how to address them
4/10/2014 Take a tour of ISMP’s website: Provide your patients with a link to the site
3/27/2014 Still outside the bull’s eye: 2014-2015 Targeted Medication Safety Best Practices (Baseline survey results)
3/13/2014 Use caution when “alternatives” are proposed with ambulatory e-Rx systems
3/13/2014 Recommendations for practitioners and manufacturers to address system-based causes of vaccine errors
8/23/2012 Generic methylergonovine and Engerix-B mix-ups due to look-alike vials
2/27/2014 ISMP Canada identifies themes associated with fatal medication events in the home
2/13/2014 How FDA can help reduce dabigatran (PRADAXA) bleeding risks
2/13/2014 Survey links PN component shortages to adverse outcomes
1/30/2014 Regarding the current IV solution shortage affecting US hospitals
1/30/2014 A mislabeling event with batched drugs: The unintended consequences of practice changes
1/16/2014 QuarterWatch (Special Report): Adverse drug events in children less than 18 years old
12/12/2013 The 16th Annual CHEERS Awards: Feel the Rhythm of Change in Medication Safety
11/28/2013 First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP)
11/14/2013 Understanding and managing IV container overfill
10/31/2013 As U-500 insulin safety concerns mount, it’s time to rethink safe use of strengths above U-100
10/17/2013 QuarterWatch ™ 2012 Annual Report Anticoagulants, anti-TNF drugs, fentaNYL patches, and alendronate
10/3/2013 Unresolved disrespectful behavior in healthcare Practitioners speak up (again)-Part I
9/19/2013 Small effort, big payoff... Automated maximum dose alerts with hard stops
9/5/2013 Death and neurological devastation from intrathecal vinca alkaloids: Prepared in syringes = 120; Prepared in minibags = 0
8/22/2013 Developing productive partnerships with technology and device vendors to improve staff training
8/8/2013 FentaNYL patch fatalities linked to “bystander apathy” We ALL have a role in prevention!
7/11/2013 In utero medication administration to fetus presents unique safety challenges
6/27/2013 Disrespectful behavior in healthcare... Have we made any progress in the last decade?
6/13/2013 Independent Double Checks: Undervalued and Misused: Selective use of this strategy can play an important role in medication safety
5/30/2013 Fatal PCA adverse events continue to happen… Better patient monitoring is essential to prevent harm
5/16/2013 Administering a saline flush “site unseen” can lead to a wrong route error
5/2/2013 Survey results show medication safety information provided by ISMP is valued and acted upon by US hospitals
4/18/2013 QuarterWatch (April 2013 issue) Perspective on GLP-1 agents for diabetes
4/4/2013 Your high-alert medication list—Relatively useless without associated risk-reduction strategies
3/21/2013 Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit
3/7/2013 Survey results: Community liaison programs to decrease hospital readmissions
2/21/2013 A clinical reminder about the safe use of insulin vials
2/7/2013 Ongoing concern about insulin pen reuse shows hospitals need to consider transitioning away from them
1/24/2013 Survey results: How hospitals are managing the preparation and purchase of high-risk compounded sterile preparations (CSPs)
1/10/2013 QuarterWatch™ (2012—Quarter 2) Signals for finasteride, methylphenidate patches, and anticoagulants
12/13/2012 The 15th Annual ISMP Cheers Awards: Meet this year’s true gems in medication safety
11/29/2012 Side tracks on the safety express. Interruptions lead to errors and unfinished… Wait, what was I doing?
11/15/2012 Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community
11/1/2012 Moving forward for safer sterile compounding
10/18/2012 Sterile compounding tragedy is a symptom of a broken system on many levels
10/4/2012 QuarterWatch™ (2012—Quarter 1) Signals for DULoxetine, pioglitazone, aliskiren, and rivaroxaban
9/20/2012 Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections
9/6/2012 Prescription drug time guarantees and their impact on patient safety in community pharmacies
8/23/2012 Avoiding inadvertent IV injection of oral liquids
8/9/2012 ISMP survey reveals user issues with Carpuject prefilled syringes
7/26/2012 Raising the index of suspicion: Red flags that represent credible threats to patient safety
7/12/2012 Just Culture and its critical link to patient safety (Part II)
6/28/2012 Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors
6/14/2012 Dr. Leape and colleagues present a compelling call to action to establish a culture of respect
5/31/2012 QuarterWatch™2011 Annual Report An estimated 2 to 4 million drug-induced serious injuries in 2011
5/17/2012 Just Culture and its critical link to patient safety (Part I)
5/3/2012 Cheers honoree’s acceptance speech creates pause for reflection
4/19/2012 A shortage of everything except errors: Harm associated with drug shortages
4/5/2012 QuarterWatch™ (second quarter 2011) Signals identified for fingolimod and inFLIXimab
3/22/2012 Results of our survey on drug storage, stability, compatibility, and beyond use dating
3/8/2012 Good intention, uncertain outcome... Our take on physician dispensing in offices and clinics
2/23/2012 Smart pump custom concentrations without hard “low concentration” alerts
2/9/2012 Results of ISMP survey on High-Alert Medications: Differences between nursing, pharmacy, and risk/quality/safety perspectives
1/26/2012 Does the CMS?standard to store medications according to manufacturer’s directions impact drug shortages and increase waste?
1/26/2012 Don’t let the “tobacco stain” on pharmacies that sell cigarettes be a barrier to advanced pharmacy practice (Report to Surgeon General calls for recognition and compensation of pharmacists)
1/12/2012 QuarterWatch™ (First Quarter 2011) Signals for dabigatran and metoclopramide
12/15/2011 14th Annual ISMP CHEERS Awards... Winners honored in New Orleans amid All that Jazz…
12/1/2011 Look out for Lugol’s... Error-prevention strategies for this strong iodine solution
11/17/2011 Conservative prescribing needed to improve medication safety
11/3/2011 Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children
10/20/2011 FDA Advise-ERR: FDA approves HYDROmorphone labeling revisions to reduce medication errors
10/6/2011 QuarterWatch™ 2010 (Quarter 4 and annual summary) Signals for two newly approved drugs: dabigatran and dalfampridine
9/22/2011 Durasal-Durezol mix-up illustrates how dangerous product problems persist long after recognition
9/8/2011 Telling true stories is an ISMP hallmark Here’s why you should tell stories, too…
8/25/2011 Gray market, black heart: Pharmaceutical gray market finds a disturbing niche during the drug shortage crisis
08/11/2011 Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment
07/28/2011 Oral solid medication appearance should play a greater role in medication error prevention
07/14/2011 Too many abandon the "second victims" of medical errors
06/30/2011 Scanner beep only means the barcode has been scanned
06/16/2011 Parents can detect, contribute to, or be affected by critical events during a child's hospitalization
06/02/2011 Safe practices in pharmacy sterile compounding areas
05/19/2011 QuarterWatchT: 2010 (Quarter 3)
New signals for liraglutide, QUEtiapine, and varenicline
05/05/2011 Multiple latent failures align to allow a serious drug interaction to harm a patient
04/21/2011 Another tragic parenteral nutrition compounding error
04/07/2011 TPN-related deaths call for FDA guidance and pharmacy board oversight of USP Chapter <797>
03/24/2011 Diabetes in website for medical professionals
03/10/2011 Oops, sorry, wrong patient!
A patient verification process is needed everywhere, not just at the bedside
02/24/2011 That's the way we do things around here!
Your ACTIONS speak louder than words when it comes to patient safety
02/10/2011 Preventing medication errors during codes
01/27/2011 ISMP QuarterWatchT Report (2010 Quarter 2) Adverse drug event signals warrant action
01/13/2011 Guidelines for timely medication administration
Response to the CMS "30-minute rule"
12/16/2010 The 13th Annual CHEERS Awards: And the Winners Are.
12/02/2010 Perilous infection control practices with needles, syringes, and vials suggest stepped-up monitoring is needed
11/18/2010 ISMP updates its list of drug name pairs with TALL man letters
11/04/2010 ISMP QuarterWatchT Report (2010 Quarter 1)
Signals for acetaminophen, dronedarone, and botulinum toxins
10/21/2010 Dakin's solution accidentally given IV
10/07/2010 Weathering the storm: Managing the drug shortage crisis
09/23/2010 Special Issue
Drug shortages: National survey reveals high level of frustration, low level of safety
09/09/2010 CMS 30-minute rule for drug administration needs revision
08/26/2010 Electronic prescribing vulnerabilities: Height and weight mix-up leads to dosing error
08/12/2010 Affirmative warnings (do this) may be better understood than negative warnings (do not do that)
08/12/2010 Generic enoxaparin syringe issue
07/29/2010 Drug shortages threaten patient safety
07/15/2010 Preventing catheter/tubing misconnections: Much needed help is on the way
07/01/2010 DTaP-Tdap mix-ups now affecting hundreds of patients
06/17/2010 ISMP QuarterWatch (Quarter 4 and 2009 totals) - Reported patient deaths increased by 14% in 2009
06/03/2010 Failure to set a volume limit for a magnesium bolus dose leads to harm
05/20/2010 Safe practice with the potent once daily opioid Exalgo
05/06/2010 Preventing errors when administering drugs via an enteral feeding tube
04/22/2010 Building Patient Safety Skills
Common pitfalls when conducting a root cause analysis
04/08/2010 Latest heparin fatality speaks loudly-What have you done to stop the bleeding?
03/11/2010 ISMP develops guidelines for standard order sets
03/25/2010 California Department of Public Health Medication Error Reduction Plan
03/11/2010 ISMP develops guidelines for standard order sets
02/25/2010 ISMP QuarterWatchT (2009 Quarters 1, 2, and 3)
Increased reports of ADEs with Zicam cold products, rosiglitazone, QUEtiapine, testosterone gel, and recalled products
02/11/2010 FDA Advise-ERR: A new look for Morphine Sulfate 100 mg per 5 mL (20 mg/mL) Oral Solution
01/28/2010 Baclofen programming error with SynchroMed II pump
Facility not made aware of company's software updates
01/14/2010 Survey shows recession has weakened patient safety net
12/17/2009 Santa checks his list twice. Shouldn't we?
12/03/2009 Eric Cropp weighs in on the error that sent him to prison
11/19/2009 Shakespeare was on target-don't be a borrower or lender
11/05/2009 Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions
10/22/2009 Oral syringes: A crucial and economical risk-reduction strategy that has not been fully utilized
10/08/2009 ISMP QuarterWatchT
Serious adverse drug event reports increase last quarter, 2008
09/24/2009 ISMP survey helps define near miss and close call
09/10/2009 How has the current economy affected patient safety?
08/27/2009 Ohio government plays Whack-a-Mole with pharmacist
08/13/2009 Plain D5W or hypotonic saline solutions post-op could result in acute hyponatremia and death in healthy children
07/30/2009 Will color-tinted IV tubing help?
07/16/2009 Process for handling elastomeric pain relief balls (ON-Q PainBuster and others) requires safety improvements
07/02/2009 Misidentification of alphanumeric symbols in both handwritten and computer-generated information
06/18/2009 Intrathecal injection warrants mask worn by clinician during procedure
06/04/2009 Icons and symbols on IV related products: Global industry must reflect on the safety aspects.
05/21/2009 Survey on LASA drug name pairs:
Who knows what's on your list and the best ways to prevent mix-ups?
05/07/2009 QuarterWatch (3rd quarter 2008)
Safety concerns with generics, Chantix aggressive behavior, and more
04/23/2009 Failed check system for chemotherapy leads to pharmacist's no contest plea for involuntary manslaughter
04/09/2009 Shared MDIs: Can cross-contamination be avoided?
03/26/2009 Fatal outcome after inadvertent injection of topical EPINEPHrine
03/12/2009 Beware of basal opioid infusions with PCA therapy
02/26/2009 Inattentional blindness: What captures your attention?
02/12/2009 Follow ISMP Guidelines to safeguard the design and use of automated dispensing cabinets (ADCs)
01/29/2009 Revatio=sildenafil=Viagra
01/15/2009 ISMP QuarterWatchT (2nd quarter 2008)
12/18/2008 Color-coded syringes for anesthesia drugs: use with care
12/04/2008 Safe practice environment chapter proposed by USP
11/20/2008 Actively caring for safety: Overcoming bystander apathy
11/06/2008 Using external errors to signal a clear and present danger
10/23/2008 ISMP's second QuarterWatch report shows sharp increase in reports of serious adverse drug events
10/09/2008 Collaboration focused on priority issues promotes safety
09/25/2008 Report and spread information about software risks
09/11/2008 Don't underestimate the impact of change on risk potential
08/28/2008 Misprogramming PCA concentration leads to dosing errors
08/14/2008 Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning
07/31/2008 Use of tall man letters is gaining wide acceptance
07/17/2008 Heparin errors continue despite prior, high-profile, fatal events
07/03/2008 Epidural-IV route mix-ups: Reducing the risk of deadly errors
06/19/2008 FDA Advise-ERR: Prevent dangerous drug-device interaction causing falsely elevated glucose levels
06/05/2008 Benefits and risks of including patients on RCA teams
05/22/2008 Managing visits from pharmaceutical sales representatives
05/08/2008 Considering insulin pens for routine hospital use? Consider this...
04/24/2008 Some red rules shouldn't rule in hospitals
04/10/2008 FDA Advise-ERR: Medication errors associated with Cerebyx
03/27/2008 There's more to the 60 Minutes story on heparin errors
03/13/2008 Resolving human conflicts when questions about the safety of medical orders arise
02/28/2008 USA Today news series: Clarifying the issues and embracing community pharmacy safety
02/14/2008 Keeping patients safe from iatrogenic methadone overdoses
01/31/2008 Fatal overdose uncovers need to rethink where pediatric IV medications are dispensed and administered
01/17/2008 ADC survey shows some improvements, but unnecessary risks still exist
12/13/2007 Celebrating 10 years of ISMP CHEERS awards
11/29/2007 Another heparin error: Learning from mistakes so we don't repeat them
11/15/2007 Errors with injectable medications: Unlabeled syringes are surprisingly common!
11/01/2007 Product-related issues make error potential enormous with investigational drugs
10/18/2007 Error-prone conditions that lead to student-nurse related errors.
10/04/2007 Potassium may no longer be stocked on patient care units, but serious threats still exist!
09/20/2007 Fluorouracil error ends tragically, but application of lessons learned will save lives
09/06/2007 Fatal 1,000-fold overdoses can occur, particularly in neonates, by transposing mcg and mg
08/23/2007 Lack of standard dosing methods contributes to IV errors
08/09/2007 Progress with preventing name confusion errors
07/26/2007 Failure to cap IV tubing and disinfect IV ports place patients at risk for infections
07/12/2007 Requirement #1-Patch should stick to the patient!
06/28/2007 Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!
06/14/2007 Infusion free-flow apparently still a risk
05/31/2007 Remote CPOE error-a situation that's more than remotely possible
05/17/2007 ISMP 2007 survey on HIGH-ALERT medications
Differences between nursing and pharmacy perspectives still prevalent
05/03/2007 Action needed to prevent dangerous heparin-insulin confusion
04/19/2007 Smart pumps are not smart on their own
04/05/2007 Failure to clearly link TYLENOL products to acetaminophen poses serious threat to safety
03/22/2007 If safety is your yardstick, measuring culture from the top down must be a priority
03/08/2007 Criminal prosecution of human error will likely have dangerous long-term consequences
02/22/2007 HIGH ALERT Medication Feature
Reducing patient harm from opiates
02/08/2007 Heed this warning! Don't miss important computer alerts
01/25/2007 The five rights: A destination without a map
01/11/2007 High-Alert Medication Feature: Anticoagulant safety takes center stage in 2007
12/14/2006 The 9th Annual ISMP CHEERS Awards: And The Winners Are...
11/30/2006 PEN injectors: Technology is not without imPENding risks
11/16/2006 Pharmaceutical industry medical device companies:
Part of the solution?
11/02/2006 Promethazine conundrum: IV can hurt more than IM injection!
Survey spurs interest in renewing efforts to prevent serious tissue damage
10/19/2006 "And the 'EYES' have it": Eardrops, that is...
10/05/2006 Harmful errors: How will your facility respond?
09/21/2006 Our long journey towards a safety-minded Just Culture
Part II: Where we're going
09/07/2006 Our long journey towards a safety-minded Just Culture
Part I: Where we’ve been
08/24/2006 Your attention please. Designing effective warnings
08/10/2006 Action needed to prevent serious tissue injury with IV promethazine
07/27/2006 ISMP comments on IOM report, Preventing Medication Errors
07/13/2006 Practitioners agree on medication reconciliation value, but frustration and difficulties abound
06/29/2006 Vincristine therapy: days "4-11" misunderstood as days 4 through 11
06/15/2006 Preventing accidental IV infusion of breast milk in neonates
06/01/2006 Rapid response team activation by patients can mitigate errors
05/18/2006 Tablet splitting: Do it only if you "half" to, and then do it safely
05/04/2006 Pump design flaws demonstrate need for practitioner involvement in FMEA
04/20/2006 Original document needed to scan orders to pharmacy
04/06/2006 IV potassium given epidurally: getting to the "route" of the problem
03/23/2006 Safety requires a state of "mindfulness" (Part II)
03/09/2006 Safety requires a state of "mindfulness" (Part I)
02/23/2006 IV vincristine survey shows safety improvements needed
02/09/2006 Pump up the volume - Tips for increasing error reporting
01/26/2006 What does your patient safety brochure really say about safety?
01/12/2006 Infusion pump double key bounce and double keying errors
12/15/2005 The 8th Annual ISMP CHEERS Awards: And the winners are...
12/01/2005 Fatal misadministration of IV vincristine
11/17/2005 Mail service and community pharmacies must work in tandem
11/03/2005 Propofol sedation: Who should administer?
10/20/2005 Preventing magnesium toxicity in obstetrics
10/06/2005 Unfortunately, this time it wasn't the equipment
09/22/2005 Paralyzed by mistakes. Preventing errors with neuromuscular blocking agents
09/08/2005 Be aware of false glucose results with point–of-care testing
08/25/2005 Safety still compromised by computer weaknesses
Comparing 1999 and 2005 pharmacy computer field test results
08/11/2005 New fentanyl warnings: more needed to protect patients
07/28/2005 High-reliability organizations (HROs):
What they know that we don't (Part II)
07/14/2005 High-reliability organizations (HROs):
What they know that we don't (Part I)
06/30/2005 Two steps forward and one step back for patient safety?
Two groups focus on improved outcomes, another on Rx "vending" machines
06/16/2005 Symlin insulin adjunct presents safety issues
06/02/2005 An exhausted workforce increases the risk of errors
05/19/2005 Practitioners anticipate punitive action from licensing bodies
05/05/2005 End the ice age-Is glacial acetic acid really needed?
04/21/2005 Building a case for medication reconciliation
04/07/2005 Patient's watchful eye and Internet lead to pump tampering
03/24/2005 Medication orders: Don't put me on hold
Joint Commission and use of the Broselow tape
Sterile cockpit
03/10/2005 Measuring up to medication safety
02/24/2005 Welcome to the State Board of (Nursing, Pharmacy, Medicine) Inquisitions
02/10/2005 The truth about hospital formularies
Survey shows many myths still exist 15 years later
01/27/2005 New dangers in the drug reimportation process: Will we know what our patients are taking?
01/13/2005 Looking forward: Make "pro-change" your New Year's Resolution
12/16/2004 Fatal gas line mix-up: How to avoid making this "gastly" mistake
2004 ISMP CHEERS for medication safety: Celebrating excellence
12/02/2004 Loud wake-up call: Unlabeled containers lead to patient's death
11/18/2004 The truth about hospital formularies: We've come a long way, or have we?
11/04/2004 FDA and the pharmaceutical industry must be more responsive for a safer healthcare system
10/21/2004 Hazard Alert!
ISMP urges immediate replacement of Brethine ampuls with vials!

Reducing "at-risk behaviors"
Part II of Patient safety should NOT be a priority in healthcare!


Patient safety should NOT be a priority in healthcare!
Part I: Why we engage in "at-risk behaviors"


Inflated risk: Inadvertent drug injections into inflation port
Potential confusion with AMARYL (glimepiride) and REMINYL (galantamine)

08/26/2004 Root causes: A roadmap to action
08/12/2004 Hospital and medical staff leadership is key to compliance with JC dangerous abbreviation list
07/29/2004 Misprogram a PCA pump? It's easy!
07/15/2004 Lowdown on lomustine: We’d hate CeeNU make this mistake
07/01/2004 An omnipresent risk of morphine-hydromorphone mix-ups
06/17/2004 Problems persist with life-threatening tubing misconnections
06/03/2004 Oops, sorry, wrong patient!Applying the JC “two-identifier” rule beyond the patient’s room
05/20/2004 The high cost of medications: A bitter pill to swallow
05/06/2004 Bicillin products: Syringe enhancements may help to prevent IV administration


Improvised drug delivery: A cause for concern
Hazard warning with BRETHINE and METHERGINE.


Burns in MRI patients wearing transdermal patches
Confusion caused by several different products with DULCOLAX brand name.


Intimidation: Practitioners speak up about this unresolved problem (Part II)


Intimidation: Practitioners speak up about this unresolved problem (Part I)


Broselow tape: Measuring the changes from 1998 to today


Safety issues with adding lidocaine to IV potassium infusions


Evidence-based medicine doesn’t preclude common sense


Template for disaster? Fatal injection into wrong port of implanted infusion pump


2003 CHEERS for medication safety: Celebrating excellence
ISMP's list of high-alert medications


Intrathecal injection of ionic contrast media may be fatal


A spectrum of problems with using color


Double-checks for endogenous and exogenous errors


Survey on high-alert medications
Differences between nursing and pharmacy perspectives revealed


Helping to remove the barriers to patient education


How sterile water bags show up on nursing units


Cultural diversity and medication safety


Is an antithyroid or antimetabolite needed?


How are you preventing acetaminophen overdoses?


Part II - How to prevent errors - Safety issues with patient-controlled analgesia


Safety issues with patient-controlled analgesia Part I - How errors occur


New data monitoring technology offers real-time reporting of impending adverse events


Blood pressure monitor tubing may connect to IV ports


Mind your “Medrols


How fast is too fast for IV push medications?


Nix the quick fix: Drug protocols require groundwork


"Looks" like a problem: ephedrine - epinephrine


U cnt abbrv “Patient Safety”


Last week was National Patient Safety Week – and what a week it was!


The virtues of independent double checks – they really are worth your time!


It’s time for standards to improve safety with electronic communication of medication orders


The reports are in…or are they? Awareness of medication error reporting programs needs a boost


Water, water, everywhere, but please don't give IV


Success with New Year's resolutions requires more than personal resolve


"Cheers" for medication safety: Celebrating those who made a difference in 2002


Watch out for this turkey - Complacency


Face it! Intimidation presents serious safety issues


Tricks but no treats: Illusions and medication errors


It doesn't pay to play the percentages


Benzocaine-containing topical sprays and methemoglobinemia


Bad "marks" for order communication


Involving non-clinical departments in patient safety discussions can reduce the risk of serious errors


The road less traveled


Accidental childhood acetaminophen overdoses illustrate our responsibility to educate parents


Pain scales don't weigh every risk


Pharmacy interventions - Part I and II from ISMP survey


What's in a name? Ways to prevent dispensing errors linked to name confusion
A medication error trifecta!


More on avoiding opiate toxicity with PCA by proxy


Atrocious labeling of plastic ampuls needs action now by FDA and manufacturers


Annenberg Conference sends a patient's message: "Nothing about me without me"


Remote order entry: Innovative practice to reduce distractions and offer 24-hour pharmacy service


Beware of erroneous daily oral methotrexate dosing


Practitioner access to the Internet: A necessity in a modern hospital


ISMP survey shows drug companies providing fewer unit dose packaged medications


Eliminating dangerous abbreviations and dose expressions in the print and electronic world


"Smart" infusion pumps join CPOE and bar coding as important ways to prevent medication errors


Shortsighted JC standard lacks understanding of pharmacist's role in prospective order review


Messages in our mailbox


The year 2001 at a glance: ISMP's medication safety "Cheers"


IV connection to tracheostomy cuff inflation port reflects larger problem


Supervision often a weak link in error prevention


To promote understanding, assume every patient has a health literacy problem


Failure Mode and Effects Analysis can help guide error prevention efforts


Systems thinking: Tap into staff creativity to unleash innovation


ISMP survey on perceptions of a nonpunitive culture produces some surprising results


It's time for a new model of accountability


The supermarkets do it - so why can't we raise the "bar" in health care?


Patient safety is all about taking that extra step


Insights into people will improve our safety systems.


Medication error or professional judgement?


New official interpretation of JC standard bans open access to pharmacy after hours


Please Don't Sleep Through this Wake-Up Call
Includes ISMP's table of dangerous medical abbrevations


Lessons Lost by the Global Pharmaceutical Industry

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