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.”

Using Just Culture To Improve Hospital Survey on Patient Safety Culture Results

On November 9, 2016, the Agency for Healthcare Research and Quality (AHRQ) hosted a webcast featuring Just Culture initiatives that helped improve scores on the Hospital Survey on Patient Safety Culture, particularly the Nonpunitive Response to Error composite. Topics discussed during the webcast included strategies used to implement Just Culture in a health care system and how these led to improved results on the survey


Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management

This page of resources was developed by the Institute for Healthcare Improvement. IHI
periodically receives urgent requests from organizations seeking help in the aftermath of a
serious organizational event, most often a significant medical error. In responding to such
requests, IHI has drawn on learning and examples assembled from many courageous
organizations over the last 15 years who have respectfully and effectively managed these crises.

Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems

The National Association for Healthcare Quality Call to Action: Safeguarding the Integrity of
Healthcare Quality and Safety Systems provides best practices to enhance quality, improve
ongoing safety reporting, and protect staff. It addresses accountability, protection of those who
report quality and safety concerns, and accurate reporting and response.

Door-to-Doc Patient Safety Toolkit

Door-to-Doc is a patient flow redesign process that improves the safety of care for patients in the
emergency department by reducing the time patients wait to be seen and by expediting admission
to the most appropriate hospital unit. A main feature is that patient flow is split into “less sick”
and “sicker” patient subgroups based on a “quick look” rather than a full triage. This has the
advantage of keeping less sick patients, which is the vast majority, flowing (rather than waiting
in the lobby) during busy times.

Coordinated-Transitional Care Toolkit

This tool was developed by the University of Wisconsin-Madison School of Medicine & Public
Health and the William S Middleton Memorial Veterans Hospital. The Coordinated-Transitional
Care (C-TraC) Toolkit is a low-resource, telephone-based, protocol-driven program designed to
reduce 30-day rehospitalizations and to improve care transitions during the early post-hospital
period. The goal of this toolkit is to help hospital systems that serve populations with high rates
of patient dispersion, cognitive impairment, and vulnerability improve care coordination and
post-discharge outcomes such as reduced medication discrepancies. The toolkit is designed to
help clinicians and researchers execute the C-TraC program protocol. In addition to the full
toolkit, C-TraC developed a COMPASS module to support hospital to nursing home transitions.

Hospital Nurse Staffing and Quality of Care

This report summarizes the findings of Agency for Healthcare Research and Quality-funded
projects and other research on the relationship of nurse staffing levels to adverse patient
outcomes. This information can be used by decision makers to make more informed choices in
terms of adjusting nurse staffing levels and increasing nurse recruitment while optimizing quality
of care and improving nurse satisfaction.

Achieving Efficiency: Lessons from Four Top-Performing Hospitals

This report from the Commonwealth Fund presents case studies of four of the 13 Leapfrog
Group-designated “Highest Value Hospitals” that offer strategies that may help hospital and
health system leaders achieve greater efficiency. During site visits conducted in 2010, hospital
leaders and staff were asked about the activities they credit with having contributed to high
quality and low resource use. Managing staffing and adjusting roles to reduce or improve
handoffs and promote teamwork to meet patient needs was cited as a way to increase efficiency.


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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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.