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...

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...

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...

Total Systems Safety Supports Practitioners in Partnering with Families to Protect Patients

Problem: The National Steering Committee for Patient Safety1 was developed and coordinated by the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ...

Survey Shows Room for Improvement with Three New Best Practices for Hospitals

In our February 22, 2024 newsletter, we invited hospitals to participate in a short survey to establish a baseline of implementation for the three new Best Practices released in the 2024-2025 ISMP ...

Call to Action: Standardization and Smarter Logic Needed to Prevent Drug Name Selection Errors

Problem: Since 2019, ISMP has recommended entering, at a minimum, the first five letter characters of a drug name (unless the name has fewer than five letters) during searches in automated dispensi...

How to Navigate the New ISMP Website

ISMP has a new website (www.ismp.org) that has been integrated with the website of our affiliate organization, ECRI, to help simplify sign-ins and streamline access to our many services and product...

Kentucky law prevents practitioners from being criminally charged for medical errors

We were pleased to learn that Kentucky Governor Andy Beshear recently signed a bill (House Bill 159) into law that protects healthcare practitioners from being criminally charged for medical errors...