List of Confused Drug Names

ISMP’s List of Confused Drug Names contains look-alike and sound-alike (LASA) name pairs, of medications that have been published in the ISMP Medication Safety Alert!® and the ISMP Medication Safety Alert!® Community/Ambulatory Care Edition through February 28, 2019.”

This list can also be used when exploring high risk medications.

High Risk Medicines

“High risk medicines are those medicines that have a high risk of causing significant patient harm or death when used in error. Although errors may or may not be more common than with other medicines, the consequences of errors with these medicines can be more devastating. To assist in preventing errors, SA Health’s High Risk Medicines safety initiative has put together a set of safety tips for specific high risk medicines.”

ISMP List of High-Alert Medications in Acute Care Settings

ISMP List of High-Alert (High Risk) Medications in Acute Care Settings

“High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. We hope you will use this list to determine which medications require special safeguards to reduce the risk of errors. This may include strategies such as standardizing the ordering, storage, preparation, and administration of these products; improving access to information about these drugs; limiting access to high alert medications; using auxiliary labels; employing clinical decision support and automated alerts; and using redundancies such as automated or independent double checks when necessary. (Note: manual independent double checks are not always the optimal error-reduction strategy and may not be practical for all of the medications on the list.)

“Based on error reports submitted to the ISMP National Medication Errors Reporting Program (ISMP MERP), reports of harmful errors in the literature, studies that identify the drugs most often involved in harmful errors, and input from practitioners and safety experts, ISMP created and periodically updates a list of potential high-alert medications. During June and July 2018, practitioners responded to an ISMP survey designed to identify which medications were most frequently considered high-alert medications. Further, to assure relevance and completeness, the clinical staff at ISMP and members of the ISMP advisory board were asked to review the potential list. This list of medications and medication categories reflects the collective thinking of all who provided input.”

AHRQ – SBAR Technique for Communication: A Situational Briefing Model

The SBAR (Situation-Background-Assessment-Recommendation) technique and tools provide a framework for communication between members of the health care team about a patient’s condition. SBAR is an easy-to-remember, concrete mechanism for framing any conversation requiring a clinician’s immediate attention and action. Free registration and login are required to download the tool.

CDC: Adult Falls

Each year, millions of older people—those 65 and older—fall. In fact, one out of three older people falls each year, but less than half tell their doctor. Falling once doubles your chances of falling again. This Fact Sheet provides information on the serious and costly impact of falls.

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation

Many organizations are uncertain about how to proceed with designing a workable solution for medication reconciliation. This link provides helpful information and tools for designing or redesigning a medication reconciliation process.

Leaders’ Role in Medical Device Safety (IHI)

This article provides recommendations and resources for improving medical device safety, including guidance for leaders, who are in a key position to ensure that medical device purchasing decisions engage core staff in the process, incorporating their input and device use experience to inform the process.

Medical Equipment Management

Medical equipment plays a vital role in healthcare; however, when equipment is not properly
used or maintained, it also can cause harm. In many instances, patient injuries occur because
of assumptions about who may use, calibrate, modify, or repair equipment.

Injuries from medical equipment also might arise from training gaps that don’t address preuse testing, preventive maintenance, malfunction reports (and incident reports), and repair
procedures.

A commitment to safety is an essential element of any process related to the use of medical
equipment — whether the medical equipment is purchased, rented, borrowed, or leased.

-MedPro Group

SAFER Guides

The SAFER Guides consist of nine guides organized into three broad groups. These guides enable healthcare organizations to address EHR safety in a variety of areas. Most organizations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern. The guides identify recommended practices to optimize the safety and safe use of EHRs. The content of the guides can be explored here, at the links below, or interactive PDF versions of the guides can be downloaded and completed locally for self-assessment of an organization’s degree of conformance to the Recommended Practices. The downloaded guides can be filled out, saved, and transmitted between team members.

Top CDC Recommendations to Prevent Healthcare-Associated Infections

This printable factsheet provides key tips to prevent healthcare-associated infections, including CAUTIs, SSIs, CLABSIs, C. difficile, and MRSA.

BLOG:

PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.