Articles
Minimizing Distractions and Interruptions During Medication Safety Tasks
Problem: A distraction occurs when an individual’s attention is drawn away from one task to a different task, or when they are trying to work on multiple tasks at the same time. An interruption occ...
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Pump Up the Volume: How to Prioritize Events and Analyze Error Data
Problem: Error reports can be used to identify local system hazards, provide analysis of uncommon events, share lessons within and across organizations, and improve patient safety culture.1 In our ...
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Latent and Active Failures Perfectly Align to Allow a Preventable Adverse Event to Reach a Patient
Problem: A physician prescribed 2 g of intravenous (IV) magnesium sulfate for a patient in palliative care to treat hypomagnesemia. To administer the dose, a night nurse went to an automated dispen...
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Isoflurane Labeled “For Animal Use Only” in Cartons of Isoflurane Intended for Human Use
ISMP has received reports from several healthcare institutions that recently received cardboard cases labeled “Isoflurane USP 100 mL” by Piramal Critical Care (NDC 66794-017-10) (Figure 1) that act...
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Adopt Strategies to Manage Look-Alike and/or Sound-Alike Medication Name Mix-Ups
ISMP has long advocated for increased awareness of look-alike and/or sound-alike medication name mix-ups and the implementation of safeguards to prevent them. To support this advocacy, ISMP maintai...
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Potassium Chloride for Injection Concentrate in EXCEL Plastic Bags
B. Braun recently announced a new presentation of potassium chloride for injection concentrate (2 mEq/mL) in a 250 mL EXCEL container plastic bag with blue and red labeling, and a blocked medicatio...
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Articles
Addressing Disrespectful Behaviors and Creating a Respectful, Healthy Workplace–Part II
In late 2021, ISMP conducted a survey on disrespectful behaviors in healthcare. Any behavior that discourages the willingness of staff or patients to speak up or interact with an individual because...
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Special Alert
Medication Safety Issues with Newly Authorized PAXLOVID
On December 22, 2021, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for PAXLOVID, consisting of oral tablets of nirmatrelvir that are co-packaged with oral t...
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Age-Related COVID-19 Vaccine Mix-Ups
Ever since the US Food and Drug Administration (FDA) authorized the emergency use of a specific formulation (10 mcg/0.2 mL) of the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine for ch...
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Additional Strategies to Improve Complete Delivery of Small-Volume Intermittent Infusions
In the December 3, 2020 newsletter, ISMP published an article to remind practitioners that up to half of the medication in a 50 mL small-volume intermittent infusion (medication diluted in a small ...
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