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Root Cause Analysis Workbook for Community/Ambulatory Pharmacy

http://www.ismp.org/tools/rca

With the release of the. Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. Community pharmacies now have access to a coordinated, extensive set of tools designed to meet regulatory requirements in the full investigation of the causes of a sentinel event. An unexpected occurrence involving death or serious physical or psychological injury or risk thereof. Trade; worksheet. See section titled: When is RCA necessary? RCA Analysis and Action Plan. Medication Safety Officers Society. 200 Lakesid...

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Medication Safety Alert! Acute Care Edition

http://www.ismp.org/Newsletters/acutecare/articles/20030220_2.asp

SPECIAL ISSUE: Do not use these dangerous. Abbreviations or dose designations. Misunderstood or misread (symbol for dram misread for "3" and minim misread as "mL"). Use the metric system. Aurio uterque (each ear). Mistaken for OU (oculo uterque-each eye). Don't use this abbreviation. Premature discontinuation of medications when D/C (intended to mean "discharge") has been misinterpreted as "discontinued" when followed by a list of drugs. Use "discharge" and "discontinue.". Tetracaine, ADRENALIN,cocaine.

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Inattentional blindness: What captures your attention?

http://www.ismp.org/Newsletters/acutecare/articles/20090226.asp

Inattentional blindness: What captures your attention? From the February 26, 2009 issue. A nurse pulls a vial of heparin from an automated dispensing cabinet (ADC). She reads the label, prepares the medication, and administers it intravenously to an infant. The infant receives heparin in a concentration of 10,000 units/mL instead of 10 units/mL and dies. A pharmacy technician labels and delivers an IV infusion to the dialysis unit. The nurse reads the pharmacy label and hangs the bag while preparing ...

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Self-Assessments

http://www.ismp.org/selfassessments/default.asp

The Institute for Safe Medication Practices (ISMP) is pleased to provide healthcare organizations with the ISMP Medication Safety Self Assessments. These tools will help you assess the medication safety practices in your institution surrounding the use of medication therapy, identify opportunities for improvement, and compare your experience with the aggregate experience of demographically similar organizations. ISMP Medication Safety Self Assessment. Registered users can login to access aggregate data).

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ISMP Educational Programs

http://www.ismp.org/educational/default.asp

ISMP considers education to be a core co mponent of its mission. If everyone in the healthcare continuum, including patients, learns more about the nature and causes of medication errors, there is a greater possibility of preventing errors and ensuring safe medication use. With this goal in mind, ISMP continually devotes time, energy, and resources to educational initiatives. Funded by unrestricted. All of ISMP’s educational programming routinely attracts large audiences. For details on specifi...

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ISMP QuarterWatch (Quarter 4 and 2009 totals) - Reported patient deaths increased by 14% in 2009

http://www.ismp.org/Newsletters/acutecare/articles/20100617.asp

ISMP QuarterWatch (Quarter 4 and 2009 totals) - Reported patient deaths increased by 14% in 2009. From the June 17, 2010 issue. During 2009, FDA received 19,551 reports of patient deaths associated with drug therapy, a 14% increase compared to 2008 and a 3-fold increase over the past decade. At least three factors contributed to the striking increase in reported deaths:. Known risks continue unabated. Some high-alert drugs—notably, powerful opioids and acetaminophen/opioid combinations—have b...Drug comp...

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Treat Medication Samples With Respect

http://www.ismp.org/newsletters/consumer/alerts/Samples.asp

Treat Medication Samples with Respect. The best way to obtain samples is when you receive a voucher from your physician that is later filled at your pharmacy. Unfortunately, not all pharmaceutical companies offer a voucher program for medication samples. The reason for the medication. The amount that you should take. The frequency with which you should take it. Special precautions for use. Any significant side effects that can be expected. If a mix-up in the dilution occurs, your dose will not be accurate.

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Medication Safety Intensive

http://www.ismp.org/educational/msi/default.asp

This unique two-day medication safety workshop will be led by ISMP faculty and other selected medication safety experts who, based on their own real-world experiences in establishing and evaluating medication safety programs, will help you maximize your effectiveness in meeting today’s medication safety challenges. At the conclusion of this workshop, participants will be able to:. Perform system-based medication error analysis. Develop error-reduction strategies around the use of high-alert medications.

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Frequently Asked Questions

http://www.ismp.org/faq.asp

FREQUENTLY ASKED QUESTIONS (Faq). What is the national medication error rate? What standards are available for benchmarking? What is the definition of a medication error? What are the “ten key elements” of the medication-use system? Won’t medication errors be prevented if nurses just follow the “Five Rights? What are "high-alert" medications? What abbreviations are dangerous? Are these evidence based? What drug names are frequently confused? What is confirmation bias? How can I measure culture? A nationa...

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Medication Safety Alert! Newsletters

http://www.ismp.org/newsletters/default.asp

The Institute for Safe Medication Practices (ISMP) makes communication and education about medication errors a priority, publishing five electronic medication safety newsletters for healthcare professionals and consumers that collectively reach more than three million readers. ISMP’s newsletters are widely recognized as some of the most timely and comprehensive medical alert systems in the world. ISMP Medication Safety Alert! Click here to pay an invoice. ISMP Medication Safety Alert! Sent monthly via em...