Articles

Call to Action: Practitioners Need to Warn Patients About Purchasing Counterfeit Drugs Online
Problem: Practitioners should be on guard for patients who may present to different healthcare settings with adverse reactions after knowingly or unknowingly taking substandard and falsified (SF) d...
Read moreArticles

Do You Know What Is Going on in Your OR? The Anesthesiology Residents' Perspective
PROBLEM: If you interviewed members of your perioperative team to ask what keeps them up at night, you might be surprised by what you uncover. The operating room (OR) represents an area with high p...
Read moreArticles

Articles

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...
Read moreArticles

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...
Read moreArticles

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 ...
Read moreArticles

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 ...
Read moreArticles

Articles

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...
Read moreArticles

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...
Read moreArticles

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...
Read moreArticles

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...
Read more