A process-driven, system-based approach to investigation of the causes of a sentinel event.
Resource Library
These resources are developed from ISMP's review of reports through its national error reporting programs, peer-reviewed articles in its publications, and/or consensus gathering summits on topics pertinent to specific errors or hazards. ISMP offers a wide range of downloadable and easy to use resources. Many are free.
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Proactively identify opportunities for reducing patient harm from chemotherapeutic agents.
Use this list to identify and promote the standard concentrations of typical neonatal drug infusions.
Designed to heighten awareness of distinguishing systems and practices in a safe hospital medication system.
Medications requiring special safeguards to reduce the risk of errors and minimize harm.
Collect critical information after a medication error or near-miss occurs. Identify, prioritize, and record problems in your facility's medication use system.
For acute care organizations developing or revising policies and procedures.
At the request of sanofi aventis , and as a public service, ISMP has agreed to provide a link to a letter from them regarding recent reports of label adherence issues with LOVENOX (enoxaparin) 30 mg and 40 mg prefilled unit dose syringes. The letter provides additional information about avoiding...
Generic enoxaparin syringe issue . In the last issue we wrote about a problem with the manufacturer’s label coming loose on certain Lovenox (enoxaparin) unit-dose syringes (30 mg and 40 mg). This week, Sandoz, which recently released generic enoxaparin, confirmed a different problem with some of its...
Understand what is required to apply and implement this technology.
Increased reports of ADEs with Zicam cold products, rosiglitazone, QUEtiapine, testosterone gel, and recalled products
This list includes selected proprietary names that contain a suffix, along with the meaning of the suffix.
Poor label design can lead to misinterpretation and errors.
Incorporate these elements when designing paper-based or electronic order sets.
Poor label design can lead to misinterpretation and errors.
Poor label design can lead to misinterpretation and errors.
Poor label design can lead to misinterpretation and errors.
Problem : In our May 21, 2009, newsletter we noted an association between the ON-Q PainBuster elastomeric pump and chondrolysis (destruction of cartilage), particularly if the local anesthetic intended to reduce pain after surgery is infused directly into a joint rather than the tissue around it....