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...

Implement Strategies to Prevent Persistent Medication Errors and Hazards: 2024

Reflecting on events that occurred in 2023, we have identified the top three medication errors and hazards that were recurring themes in the ISMP Medication Safety Alert!, which our affiliate ...

Three New Best Practices in the 2024-2025 Targeted Medication Safety Best Practices for Hospitals

ISMP has released its 2024-2025 Targeted Medication Safety Best Practices for Hospitals, whose purpose is to identify, inspire, and mobilize widespread, national adoption of consensus-based Best Pr...

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...

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...

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...

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...

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...

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...

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...