Problem: Are you ready for the design changes coming soon for enteral feeding device connectors? While ISMP and other organizations and agencies have repeatedly publicized the upcoming global changes with all enteral device connectors, we are not confident that healthcare organizations are...
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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A process-driven, system-based approach to investigation of the causes of a sentinel event.
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.
Incorporate these elements when designing paper-based or electronic order sets.
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...
Pinpoint specific system weakness and provide a starting point for successful organizational improvements.
On March 17, 2008, CBS aired a 60 Minutes segment featuring interviews with Dennis Quaid and his wife Kimberly Buffington who shared their thoughts about the medication errors that happened to their newborn twins in November 2007. The errors involved the accidental administration of heparin...
At the start of each year, ISMP has often encouraged organizations to select and follow a New Year’s resolution related to medication safety. This year we, too, have made a New Year’s resolution: To highlight for our readers key information about selected high-alert medications and how to reduce...