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...

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 ...

A Recurring Call to Action: Every Healthcare Organization Needs a Medication Safety Officer!

Medication safety is a serious responsibility that is vital to the sustainability of healthcare organizations.1 On average, hospitalized patients experience one medication error each day,2,3 and pr...

Hidden Medication Loss When Using a Primary Administration Set for Small-Volume Intermittent Infusions

While covering for a colleague during patient rounds in an adult medical unit, a pharmacist noticed two empty 50 mL minibags of ZOSYN (piperacillin and tazobactam) hanging on a patient’s intravenou...

Dangerous Wrong-Route Errors with Tranexamic Acid

We recently learned about three cases of accidental spinal injection of tranexamic acid instead of a local anesthetic intended for regional (spinal) anesthesia. Container mix-ups were involved in e...

The Differences Between Human Error, At-Risk Behavior, and Reckless Behavior Are Key to a Just Culture

Do you believe your organization operates within a Just Culture? We have asked this question many times while working collaboratively with healthcare organizations and professionals. It is not an e...

Speaking Up About Patient Safety Requires an Observant Questioner and a High Index of Suspicion

Healthcare practitioners are expected to speak up about patient safety concerns to help intercept errors and avoid adverse patient outcomes. By ‘speaking up,’ we mean raising concerns for the benef...

Independent Double Checks: Worth the Effort if Used Judiciously and Properly

Manual independent double checks of certain high-alert medications have been widely promoted in healthcare to help detect potentially harmful errors before they reach patients.1,2 Many practitioner...

Dangerous Wrong-Route Errors with Tranexamic Acid—A Major Cause for Concern

Problem: Earlier this month, we were notified about two cases of accidental intraspinal injection of tranexamic acid, occurring in two different states. Unfortunately, the report was sent anonymous...

Mix-ups Between Epidural Analgesia and IV Antibiotics in Labor and Delivery Units Continue to Cause Harm

Problem: Within weeks of each other, two hospitals have reported mix-ups between epidural analgesia and intravenous (IV) antibiotics in labor and delivery (L&D) units. These mix-ups mimic previ...

Check for Proper Nucala Dose Preparation

If you are using NUCALA (mepolizumab) for patients who have eosinophilic asthma, please check to ensure the correct volume is being dispensed. In a Safety Brief in our June 28, 2018 newsletter, we ...

Severe Under Dosing of Insulin With U-500 Pen

An emergency department (ED) pharmacist was talking to a patient about his U-500 insulin dose. The patient, who had been using a U-500 insulin pen, told the pharmacist that his dose was 75 units b...