Tranexamic Acid Injection Added to ISMP’s List of High-Alert Medications
Tranexamic acid injections have been added to the Institute for Safe Medication Practices’ (ISMP’s) 2024 List of High-Alert Medications in Acute Care Settings. “High-alert” medications have an increased risk of causing significant harm to patients when they are incorrectly administered. ISMP recommends that practitioners implement safeguarding measures to minimize the risk of error when dispensing […]
Read More ›ISMP Safety Brief: Prevent Additional Patient Harm and Deaths From Accidental Daily Methotrexate Dosing
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. Methotrexate is a folic acid antagonist that was originally approved to treat a variety of cancers. Used for oncologic indications, methotrexate is administered in cyclical frequencies and in variable doses based on body surface area and the type of cancer […]
Read More ›ISMP Safety Brief: Unintentional Ingestion of Boric Acid Vaginal Suppositories
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. A doctor told a woman with a vaginal infection to use boric acid suppositories to help relieve symptoms that often accompany vaginitis, such as a bad odor. Boric acid (a pesticide that is harmful when taken orally) suppositories are sold […]
Read More ›ISMP Launches the 2023-24 Targeted Medication Safety Best Practices for Community Pharmacy
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. The Institute for Safe Medication Practices (ISMP) has launched the 2023-24 Targeted Medication Safety Best Practices for Community Pharmacy (Best Practices). The purpose of these Best Practices is to identify, inspire, and mobilize widespread, national adoption of consensus-based best practices […]
Read More ›ISMP Safety Brief: Confusion Among the Many Humira Products With More Biosimilars on the Horizon
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. A specialty pharmacy reported concerns with look-alike packaging with the many presentations of Humira® (adalimumab), which is used for nine different autoimmune indications in both pediatric and adult populations. The manufacturer produces 20 different prefilled syringe and pen carton configurations. […]
Read More ›ISMP: Common Workaround Contributes to Override of Barcode Alert
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. A specialty pharmacy filled a prescription for Jakafi® (ruxolitinib) 5 mg tablets with 15 mg tablets by mistake and shipped it to the patient. Jakafi is a kinase inhibitor used to treat myelofibrosis and polycythemia vera in adults, and graft-versus-host […]
Read More ›ISMP: Restarting Clozapine Too Rapidly Can Cause Severe Cardiovascular Effects
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. A patient presented to a hospital with agitation and confusion. He had a history of bipolar disorder for which he had been prescribed (off-label) the antipsychotic clozapine (CLOZARIL®). However, he had not taken the clozapine for several weeks more than […]
Read More ›ISMP: Respond to consumers’ error concerns with empathy and honesty
This column was prepared by the Institute for Safe Medication Practices, an ECRI affiliate. The Institute for Safe Medication Practices (ISMP) receives frequent reports of medication errors directly from patients. While patients are understandably concerned about errors, the patients who report to us are usually more upset about the response (or lack of) from the […]
Read More ›ISMP Provides Safe Practice Recommendations to Prevent COVID-19 and Flu Vaccine Mix-Ups
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. Multiple mix-ups between the pediatric formulation (ages five through 11 years; orange cap and label border) and the formulation for individuals 12 years old or older of the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) Vaccine have been reported to the Institute […]
Read More ›ISMP Warns of Possible Confusion With InPen Insulin Pen Systems
This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate. The Institute for Safe Medication Practices (ISMP) has received a report from an outpatient pharmacy regarding a close call with a product called InPen a Bluetooth-connected “smart” insulin pen system for mealtime insulins that is prescribed with either insulin aspart […]
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