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.”

Health Information Technology Toolkit for Physician Offices

The Health Information Technology Toolkit for Physician Offices helps these health care
organizations assess their readiness, plan, select, implement, make effective use of, and exchange
important information about the clients you serve. The toolkit contains numerous resources,
including tools for telehealth, health information exchange, and personal health records.

Electronic Medical Record-Facilitated Workflow Changes Enhance Quality and Efficiency, Generating Positive Return on Investment in Small Pediatrics Practice

This featured profile is available on the Agency for Healthcare Research and Quality’s Health
Care Innovations Exchange Web site. Four Seasons Pediatrics, a three-physician group in upstate
New York, redesigned its workflow, reduced staffing costs, and enhanced quality of care while
adopting an electronic medical record. The group also achieved a positive return on investment
within 2.5 years, earning financial rewards through the Bridges to Excellence program and other
pay-for-performance programs.

2015 National Patient Safety Goals: Ambulatory Care

The purpose of the Joint Commission Ambulatory Care National Safety Goals is to improve
patient safety in an ambulatory setting by focusing on specific goals.

Decrease Demand for Appointments

One key way for a health care system to improve access is to reduce unnecessary demand for
various services so that patients needing a particular service can receive it in a timely way.
This Institute for Healthcare Improvement Web page contains information on decreasing demand
for appointments, such as using alternatives to in-person visits (e.g., telephone, e-mail).

. Balance Supply and Demand on a Daily, Weekly, and Long-Term Basis

The foundation of improved access scheduling is matching supply and demand on a daily,
weekly, and monthly basis. This Institute for Healthcare Improvement Web page contains
information on communication methods to manage the daily and weekly supply and demand
variation and to anticipate and plan for recurring seasonal events.

E-Mail Enhances Communication With and Access to Pediatrician for Patients and Families

This featured profile is available on the Agency for Healthcare Research and Quality’s Health
Care Innovations Exchange Web site. A pediatric subspecialist offered the families of his
patients the opportunity to contact him via e-mail, with formal guidelines established with
respect to the appropriate use of the system (e.g., content, length, response time). More than 90
percent of families offered the service enrolled, with approximately 40 percent using the service
during a 2-year period. Families using the service reported enhanced communication with and
access to the pediatrician. The physician found that use of the e-mail service saved him time
versus answering the same inquiries via telephone. In addition, over time, the program has
engaged more teenagers to contact the doctor directly using electronic communication.

Patient Safety and the “Just Culture”

This presentation by David Marx defines just culture, the safety task, the just culture model, and
statewide initiatives in New York.


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.