Implement Strategies to Prevent Persistent Medication Errors and Hazards: 2025

Reflecting on events that occurred in 2024, we have identified four concerns related to medication safety, which were included in ECRI’s Top 10 Patient Safety Concerns for 2025 or ECRI’s Top 10 Hea...

Action Needed to Address Risk With Custom and Multi-Chamber Bag Parenteral Nutrition—Part II

PROBLEM: The complexity of parenteral nutrition (PN) coupled with the heightened risk of causing significant patient harm when used in error, calls for targeted safeguards throughout the medication...

Survey Exposes Risks with Custom and Multi-Chamber Bag Parenteral Nutrition—Part I

PROBLEM: Parenteral nutrition (PN) is a complex life-sustaining therapy for patients who cannot intake adequate oral or enteral nutrition. It can contain more than 40 ingredients and is considered ...

A Deeper Dive into Active Failures and Accountability Using Just Culture Principles—Part II

PROBLEM: In our last newsletter, in the main article, Another case of nursing criminalization – Long-term care facilities must improve systems, not blame nurses - Part I, we discussed how a series ...

Targeted Medication Safety Best Practices for Community Pharmacy

Developed to identify, inspire, and mobilize adoption of consensus-based Best Practices for specific medication safety issues in community pharmacy that can cause patient harm.

Worksheet for the ISMP Targeted Medication Safety Best Practices for Community Pharmacy

Analyze your current status with implementation.

Another Case of Nursing Criminalization—Long-Term Care (LTC) Must Improve Systems, Not Blame Nurses—Part I   

This ISMP Medication Safety Alert!® Acute Care newsletter article describes another case in which a nurse, this time working in long-term care (LTC), was criminally indicted after a patient died du...

MERP Annual Review Exposes How Manufacturer Labeling/Quality Issues Impact Medication Safety

From July 1, 2023, through June 30, 2024, a total of 1,016 voluntarily submitted reports were sent to the ISMP National Medication Errors Reporting Program (ISMP MERP). Healthcare practitioners uti...

ISMP 27th Annual Cheers Awards: Making Medication Safety Magic

This week, ISMP celebrated the 27th annual CHEERS AWARDS, which recognize individuals, organizations, and groups that have demonstrated extraordinary commitment to advancing the science and study o...

Take Action to Prevent Tubing Misconnections—Part II

Problem: Tubing misconnections, or inappropriate connections between devices with different intended uses, have resulted in serious harm or death.1,2 In Part I, published in our October 31, 2024 ne...

Fluid shortage update—Safeguard imported products

Baxter announced it plans to restart manufacturing intravenous (IV) solutions at its North Cove, North Carolina facility this week. In the interim, as most readers are aware, the US Food and Drug A...

Survey Results Reveal Tubing Misconnections Are Common and Underreported—Part I

Problem: Tubing misconnections refer to what happens when a tube, syringe, or medical device from one delivery system is inappropriately connected to a system that serves a completely different fun...

Imported Fluid Product Checklist

This tool was developed to assist organizations in conducting a gap analysis when evaluating imported products safety during the fluid shortage crisis following the Hurricane Helene aftermath.

Weathering the storm— Safety considerations during fluid shortages

Problem: As most readers are aware, on September 29, 2024, Baxter announced that their North Cove, NC manufacturing plant was temporarily closed due to damage from Hurricane Helene. This facility i...

ISMP National Vaccine Errors Reporting Program 2022-2023 Analysis: New Vaccines, New Errors

Problem: Though immunization is one of the greatest public health achievements, continued success relies on the appropriateness with which vaccines are prescribed, dispensed, stored, and administer...

Vaccine Bi-Annual Report

An analysis of vaccine error reports submitted to the ISMP National Vaccine Errors Reporting Program (ISMP VERP) during calendar years 2022 and 2023.

Reducing Inappropriate Polypharmacy through Deprescribing

Polypharmacy refers to the simultaneous use of multiple medications. It can lead to risks such as drug interactions, increased side effects, medication non-adherence, and cognitive impairment. Lear...

Can We Ensure Medication Safety with the Use of Speech Recognition Software?

Problem: Speech recognition, or speech-to-text, is the ability of a computer software system to identify spoken words and then convert them into readable text. It is something most people use daily...

Use Barcode Scanning to Prevent Errors with Enteral Nutrition Feedings

Problem: The safe use of enteral nutrition (EN) in the hospital setting is often taken for granted. However, when viewed closely, the process is often fraught with potential failure points. Challen...

NAN Alert! Manufacturer’s dexmedeTOMIDine premixed IV bags may be packaged within an overwrap labeled as acetaminophen

A Hikma product with an overwrap labeled acetaminophen injection 1,000 mg/100 mL (NDC 0143-9386-01,  lot  number  24070381, expiration date 09/2025) (Figure 1), may contain a dexmedeTOMIDine 400 m...

List of Confused Drug Names

Also known as the Look-alike and sound-alike (LASA) list.