IMSN members publications

Click to have a look on the publications issued by each IMSN member

Danish Patient Safety Authority - Styrelsen for Patientsikkerheds læringsenhed


The Danish Patient Safety Authority is responsible for the administration of the system for reporting inadvertent incidents within the health service, and helps to make sure that the knowledge gained from these incidents and complaints and liability suits is used preventatively. The incidents are administrated in the Danish Patient Safety Database.

  • Focus on patient safety
    Focus on patient safety provides insight into our ongoing national patient safety efforts and is addressed to anyone who is interested in patient safety.
    Periodicity: twice a year
    Publication langage: Danish
    Free subscription for broadcast
    Access to the Focus on patient safety : Read on...

     

    What's new in the last Focus on patient safety?

    - Reporting on vaccination against COVID-19
    - Modernization of the IT platform Danish Patient Safety Database
    - Major pilot test of changed reporting scheme of adverse events is now being evaluated
    - Local initiatives for patient safety
    - New information material to prevent osteonecrosis of the jaws
    - Five new guidelines will help healthcare professionals keep records
    - New care locations in the Danish Patient Safety Database
    - Medication review and WHO Initiative Medicine without harm
    - Amendments to the Health Act provide a new framework for work on patient safety

  • Attention notes
    The Attention notes are issued when serious or fatal incidents are registered by the Danish Patient Safety Authority in the Danish Patient Safety Database.
    Periodicity: as needed
    Publication langage: Danish
    No Subscription. Available for free download.
    Access to the Danish Patient Safety Authority’ Attention notes: Read on...

     

    What are the last medication attention notes?

    28 July 2020 - Risk of incorrect dosing due to shortage of Digoxin 250 micrograms Read on…
    15 January 2020 – Mix-up between AmBisome° and Fungizone° against fungal infections can have serious consequences Read on…
    2 July 2019 - Pradaxa° capsules should remain in the original package until use Read on…
    26 February 2019 - Doubt about dosing when switching between Tresiba° 100, FlexTouch° and Tresiba° 200, FlexTouch° Read on…
    9 November 2018 - Be aware of the risk of error dosing with the Xarelto° Starter Kit Read on...
    12 September 2017 - Bupivacaine must not be given intravascularly Read on...
    7 September 2017 - Observe correct dosage of methotrexate Read on...
    30 June 2017 - Be aware of the interaction between warfarin and miconazole oral gel Read on...
    16 December 2016 - Risk of confusion between Gardasil° and the MMR vaccine Read on...
    9 March 2016 - Dement patients and patches Read on... ; It goes wrong when the patch must be changed Read on...
    15 June 2015 - Pradaxa® capsules should remain in the blister pack until use Read on...

  • Other publications
    Other publications are issued on request or when serious, fatal or repeated incidents are registred by the Danish Patient Safety Authority in the Danish Patient Safety Database.
    Periodicity: not applicable
    Publication langage: Danish
    No Subscription. Available for free download.
    Access to the Danish Patient Safety Authority’ other publications: Read on...

     

    What are the last other publications?

    2014 - Insulin use - identification of adverse events and proposals for preventive measures Read on...
    2014 - Thematic Report on the observation of patients in hospitals Read on...
    2013 - Thematic Report on dose dispensing Read on...
    2013 - Medication in housing and other services for people with disabilities Read on...

Hong Kong Hospital Authority

  • Medication Safety Bulletin
    The Medication Safety Bulletin (MSB) is published biannually (May and November) to serve as an educational publication to share issues related to medication safety.
    Periodicity: twice a year
    Publication langage: English
    No subscription. Available for free download.
    Access to Medication Safety Bulletin: Read on...

     

    What's new in the last issue?

    - Highlights of The Medication Safety Forum 2020
    - Updates of MSC Guidelines in 2021
    - Adverse Event Following Immunization (AEFI) for COVID-19 Vaccines
    - Sharing from HKWC: Does Body Weight Matter in Dosing Adult Patients? A Case Sharing of Intravenous Paracetamol Overdose and Creation of Hospital Drug Set

  • Risk Alert
    A risk management newsletter for Hong Kong Hospital Authority healthcare professionals
    Periodicity: four issues by year
    Publication langage: English
    No subscription. Available for free download.
    Access to Risk Alert: Read on...
    What's new in the last issue?

    - Opening Message: Cognitive Bias and Medical Error
    - Sentinel Events (SEs) (Q1 2021)
    - Serious Untoward Events (SUEs) (Q1 2021) Medication errors: Phenytoin, High alert medication infusion

Irish Medication Safety Network

  • The Medication Safety Minute
    1-min medication safety messages compiled by Eileen Relihan, Una Kennedy and Barry O’Connell from St. James’s Hospital, Dublin for their hospital prescribers.
    Periodicity: once a week
    Publication langage: English
    No subscription. Available on Twitter @medsafetymin
    Access to The Medication Safety Minute: Twitter

     

    What's new in the last issue?

    - Can you identify the SSRI-related adverse effect?

  • IMSN Safety Alerts
    IMSN medication safety briefings and alerts are published in the Pharmacy Journal and Clinical Indemnity Scheme Newsletter
    Periodicity: as needed
    Publication langage: English
    No Subscription. Available for free download.
    Access to IMSN Safety Alerts: Read on...

     

    What's the last alert?

    April 2020 - COVID-19 Drug Check Read on…
    November 2019 - IMSN Safety Alert: Risks with IV paracetamol (version 2, update of original alert published in January 2012) Read on…
    9 April 2019 - CycloGEST CytoTEC errors in pregnancy. Read on…
    08 January 2019 - Reducing harm from omitted & delayed Parkinsons Disease medication Read on…
    21 November 2017 - IMSN Safety Alert: Safe Use of Prostaglandin Analogues in Obstetrics Read on…
    7 April 2017 - IMSN Safety Alert: Risks associated with High-Strength Insulin Preparations Read on…
    October 2016 - IMSN Safety Alert on Allergy and Anaphylaxis to Known Drug Allergens (update of original alert published in October 2012) Read on…
    July 2016 - IMSN Safety Alert: Risk of Cross-contamination with Insulin Pens (update of original alert published in November 2013) Read on…
    July 2016 - IMSN Safety Alert: Confusion Risk with trastuzumab EMTANSINE (Kadcyla®) and trastuzumab (update of original alert published in July 2014) Read on…
    October 2015 - IMSN Safety Alert: IV Magnesium Sulphate in Obstetrics Read on…
    May 2015 - IMSN Safety Alert on Novel Oral Anticoagulants (NOACs) Read on…

ISMP Brasil

  • Boletim ISMP Brasil
    The ISMP Brasil Newsletter aims to disseminate relevant information on medication errors at all levels of health care. In each edition, topics of interest for institutions, health professionals and society are addressed.
    Periodicity: four to five issues by year
    Publication langage: Portuguese
    No Subscription. Available for free download or sent by e-mail to registered users.
    Access to Boletim ISMP Brasil: Read on...
    Follow ISMP Brasil on Twitter
    What's new in the last issue?

    Prevention of medication errors during the pandemic

  • Safety Alerts
    Periodicity: as needed
    Publication langage: Portuguese
    No Subscription. Available for free download.
    What's the last alert?

    January 2020 - Prevent administration errors involving vincristine Read on…
    March 2019 - Prevent administration errors with penicillins! Read on…
    January 2019 - Prevent administration errors involving syringes! Read on…
    April 2017 - Mix-up risk between vaccine vials Read on...
    August 2016 - Mix-up risk with vials of injectable potassium chloride Read on...
    28 April 2016 - Mix-up risk with flu vaccine vials Read on...

ISMP Canada

  • ISMP Canada Safety Bulletin
    The purpose of the bulletins is to confidentially share the information received about medication incidents which have occurred and to suggest medication system improvement strategies for enhancing patient safety. The bulletins will also share alerts and warnings specific to the Canadian market place.
    Periodicity: 10 to 13 issues by year
    Publication langages: English and French
    No Subscription (excepted for commercial corporations or Government agencies).
    Available for free download or sent by e-mail to registered users.
    Access to the ISMP Canada Safety Bulletin: Read on...
    Access to the Bulletin de l’ISMP Canada: Read on...
    Follow ISMP Canada on Twitter

     

    What's new in the last issue?

    - Updated Analysis and Shared Learning from COVID-19 Vaccine Errors
    - SafeMedicationUse.ca  Calcium and Medications Often Don't Mix
    - Oxytocin to Start or Advance Labour: 5 Questions to Ask

  • ISMP Canada Alerts
    Periodicity: as needed
    Publication langage: English and French
    Available for free download or sent by e-mail to registered users.
    Access to ISMP Canada Alerts: Read on...

     

    What's the last alert?

    6 May 2021 - ALERT: Rocuronium Vials Lack Recommended Warning on Ferrule Read on...
    15 October 2020 - ALERT: Risk of Inadvertent Reconstitution of Medications with Cleaning Products Read on...
    1 May 2020 - ALERT: Hand Sanitizers that Look Like Drinks Read on...
    7 December 2017 - ALERT: Polyethylene Glycol and Propylene Glycol Mix-up Causes Harm Read on...
    9 September 2015 - ALERT: Methylene Blue Interaction Leads to Serotonin Syndrome Read on...
    31 March 2015 - ALERT: Shortage of Topical Epinephrine 1:1000 Poses Safety Risks Read on...

  • SafeMedicationUse.ca Safety Newsletter for Consumers
    SafeMedicationUse.ca provides a better way for consumers to report medication incidents and to get information about using medication safely.
    Periodicity: 8 to 10 issues by year
    Publication langages: English and French
    No Subscription. Available for free download or sent by e-mail to registered users.
    Access to the SafeMedicationUse.ca Safety Newsletter for Consumers: Read on...
    Access to the Bulletin de Médicamentssécuritaires.ca: Read on...

     

    What's new in the last issue?

    - Back to School: Keeping Children with Severe Allergies Safe

  • SafeMedicationUse.ca Safety Alert for Consumers
    SafeMedicationUse.ca provides a better way for consumers to report medication incidents and to get information about using medication safely.
    Periodicity: 8 to 10 issues by year
    Publication langages: English and French
    No Subscription. Available for free download or sent by e-mail to registered users.
    Access to SafeMedicationUse.ca Safety Alert for Consumers: Read on...
    Access to Médicamentssécuritaires.ca Alerte: Read on...

     

    What's the last alert?

    31 March 2014 - More Reports of Eye Injuries Involving Clear Care Read on...

  • Ontario Critical Incident Learning Bulletin
    Funding for this bulletin and the associated knowledge translation project is provided by the Ontario Ministry of Health and Long-Term Care.
    Periodicity: four to five issues by year
    Publication langage: English
    No subscription. Available for free download.
    Access to Ontario Critical Incident Learning: Read on...

     

    What's new in the last issue?

    - Strengthening Medication Reconciliation (MedRec) at Discharge

  • Regular columns in professional journals
    From 1999 to 2010, ISMP Canada articles were published in regular columns that appear in the Canadian Journal of Hospital Pharmacy (CJHP), in Hospital News, and less frequently in the Canadian Pharmacists Journal, the official publication of the Canadian Pharmacists Association.

     

    CACCN Dynamics

    CACCN Dynamics is a journal published by the Canadian Association of Critical Care Nurses.
    Publication langage: English
    Access to ISMP Canada column in CACCN Dynamics: Read on...

    Healthcare Quarterly

    Healthcare Quarterly' objectives are to document and disseminate leading practices in health service delivery and policy development and to help Canadian health system managers anticipate and respond to changing environments, demands and mandates. Healthcare Quarterly’s target audience is decision and policy makers in governments, regions, networks, hospitals and facilities across Canada and internationally.
    Publication langage: English
    Access to ISMP Canada articles in Healthcare Quarterly: Read on...

    Pharmacy Connection

    Pharmacy Connection is the official publication of the Ontario College of Pharmacists.
    Publication langage: English
    Access to ISMP Canada column in Pharmacy Connection: Read on...

ISMP España

  • ISMP España Boletin
    The contents of this newsletter with recommendations for prevention of medication errors have been made from the reports sent by health professionals to the medication errors reporting and learning programme financed by the Spanish Ministry of Health, Social Services and Equality.
    Periodicity: 1 to 6 issues by year
    Publication langage: Spanish
    No subscription. Available for free download.
    Access to ISMP España Boletin: Read on...
    Follow ISMP España on Twitter
    What's new in the last issue?

    Top 10 Types of High Risk Medication Errors Reported in 2020

  • ISMP España Alertas
    Periodicity: as needed
    Publication langage: Spanish
    No subscription. Available for free download.
    Access to ISMP España Alertas: Read on...

     

    What's the last alert?

    April 2016 - Change in the presentation of Methotrexate Wyeth° 2.5 mg tablets to prevent medication errors Read on...
    12 July 2012 - Risk of error in the preparation of cabazitaxel (Jevtana°) Read on...

  • Labeling/packaging prone to errors
    Periodicity: as needed
    Publication langage: Spanish
    No subscription. Available for free consultation.
    Access to ISMP España Labeling/packaging prone to errors: Read on...

     

    What are the last alerts?

    8 September 2021 - Risk of confusion between Mycophenolate mofetil Accord° 250 and 500 mg and Mycophenolic Acid Accord° 180 and 360 mg
    26 August 2021 – Risk of confusion in the packaging of Gine-Canestén° 100 mg and 500 mg vaginal tablets
    14 August 2021 - Risk of errors associated with the labeling of Hepaxane° (enoxaparin) pre-filled syringes
    26 May 2021 - Risk of confusion between Tiaprizal° 100 mg / 2 mL (tiapride) and Metoclopramide Kern Pharma° 10 mg / 2 mL ampoules
    18 May 2021 – Recall of the risk of dosage errors associated with the labeling of Inhixa° (enoxaparin)
    28 March 2021 - Risk of dosing errors with Esbriet° (pirfenidone) 267 mg coated tablets
    30 December 2020 - Confusion between the packages of Cisatracurio Normon° 10 mg/5 mL and 20 mg/mL solution for injection
    26 December 2020 – Recall of the risk of confusion between Midazolam Normon° ampoules of 5 mg/5 mL and 15 mg/3 mL
    30 November 2020 - Risk of confusion between 10 mL plastic ampoules of Bupivacaine B. Braun° 2.5mg/mL, 5 mg/mL and 7.5 mg/mL
    28 November 2020 - Risk of dosage errors associated with the labeling of Inhixa° (enoxaparin)
    28 August 2020 - Confusion between the ampoules of Elgadil° 5 mg/mL (urapidil) and Eufilina° 200 mg/10 mL (theophylline) solution for injection
    20 August 2020 - Risk of confusion between Morphine B Braun° 1 mg/mL and 10 mg/mL solution for injection
    21 July 2020 - Dosage errors associated with the labeling of Heparin sodium Rovi° solution for injection
    28 June 2020 – Recall of the risk of confusion between Solinitrine Fuerte° 5 mg/mL amp 10mL and Noradrenaline Normon° 1mg/mL amp 10mL
    29 February 2020 - Risk of confusion between Syntocinón° 10 IU/1 mL (oxytocin) and Nuvacthen Depot° 1 mg/1 mL (tetracosactide) packages
    22 February 2020 - Confusion persists between packages and blister packs of Misofar° vaginal tablets of 25 and 200 micrograms (see previous alert of 30 June 2017)
    18 February 2020 - Still risk of confusion between the ampoules of Fentanest° 0.15 mg / 3 mL (fentanyl) and Ondansetron Normon° 4 mg / 2 mL and Petidine hydrochloride GES° 100 mg / 2 mL (see previous alert of 8 June 2016)
    6 December 2019 – Recall of the risk of confusion between ampuls of Tramadol Normon° 100 mg / 2 mL and Mepivacaine Normon° 2% solution for injection 2 mL (see previous alert of 23 November 2017)
    28 November 2019 - Change of the labeling of the ampuls of Suplecal° Mini-Plasco solution for injection 10 mL
    28 September 2019 - Recall of the risk of confusion between the 10 mL ampoules of 2% Mepivacaine and 2.5 mg / mL Levobupivacaine Normon
    23 August 2019 - Confusion between Midazolam Normon° ampoules of 5 mg / 5 mL and 15 mg / 3 mL
    14 August 2019 - Risk of confusion between ampoules of  Syntocinon° 10 IU/1 mL (oxytocin) and Synacthén° 0.25 mg/1 mL (tetracosactide)
    25 July 2019 - Risk of confusion between outer packages of Efavirenz Aurovitas° 600 mg and Abacavir/Lamivudine Aurovitas° 600 mg/300 mg coated tablets
    29 June 2019 – Recall of the risk of dosing errors with Nexavar° (sorafenib) tablets 200 mg
    22 June 2019 - Risk of confusion between 500 mL bottles of Glucose 5% and Glucose hypertonic 20% and 40% from Fresenius Kabi
    26 April 2019 - Confusion between the presentations of Mitomycin-C° 10 mg and 40 mg
    26 March 2019 - Still risk of intravenous administration of drinkable ampoules of Hydroferol° (calcifediol) 0.266 mg
    12 February 2019 - Risk of confusion between Ropivacaine° B. Braun 20 mg / 10 mL and 75 mg / 10 mL
    6 November 2018 - Confusion of the 10 mL plastic ampoules of Bupivacaine° B.Braun 2.5 mg / mL, 5 mg / mL and 7.5 mg / mL with those of Physiological Serum° B.Braun
    26 October 2018 - Risk of dosing errors associated with the labeling of Nucala° 100 mg vial
    20 October 2018 - Confusion between Fresubín° Original 500 mL and Fresubín° Original Fiber 500 mL
    5 June 2018 - Risk of dosing errors associated with the labeling change of Ranitidine Normon° 50 mg / 10 mL ampoules
    10 April 2018 - Risk of confusion between the capsules of Revlimid° 15 mg and Revlimid° 25 mg (lenalidomide)
    26 February 2018 - Risk of confusion between MicardisPlus° (telmisartan/hydrochlorothiazide) tablets 40 mg/12.5 mg and 80 mg/12.5 mg
    15 February 2018 - "We said yesterday": omission in the administration of trimethoprim when using Soltrim° injectable (sulfamethoxazole + trimethoprim)
    29 January 2018 - Recall of the risk of incorrect storage of vials of Zerbaxa° 1 g/0.5 g (ceftozolan/tazobactam)
    22 January 2018 - Dosage errors due to confusion between budesonide nebulizing ampoules of 0.5 mg / 2 mL and 1 mg / 2 mL (Budesonide Aldo-Unión° or Pulmicort°)
    9 January 2018 - "We said yesterday": confusion between Sandostatin° ampoules 0.05 mg (octreotide) and Sandimmun° 50 mg (ciclosporin)
    23 November 2017 - Confusions continue between the ampuls of Tramadol Normon° 100 mg / 2 mL and Mepivacaine Normon° 2% solution for injection 2 mL
    18 November 2017 - Risk of confusion between the packages of Etoposide Tevagen° 100 mg / 5 mL and Fludarabine Teva° 50 mg / 2 mL
    10 November 2017 – Risk of confusion between vials of CellCept° 500 mg (mycophenolate mofetil) and Meropenem Aurovitas° 1000 mg
    28 October 2017 - Confusion between oral ampuls of Hydroferol° (calcifediol) 0.266 mg and injectable ampoules of Furosemide Gesfur° 20 mg
    30 June 2017 - Confusion between the packs and the blisters of Misofar° vaginal tablets of 25 and 200 micrograms
    22 June 2017 - Risk of dosing errors with Sprycel (dasatinib) coated tablets 50 and 70 mg
    6 June 2017 - Confusion between IV Minibags Levobupivacaine Normon° 0.625 mg/mL 100 mL and Levofloxacin Normon° 5 mg/mL 100 mL
    16 February 2017 - Risk of confusion between ampuls of Ropivacaine GES° 2 mg/mL 10 mL and Magnesium Sulfate Genfarma° 1.5 g/10 mL
    26 January 2017 - Confusion between 10 mL plastic ampoules of Lidocaine B Braun° and Glucocemin° 33% Braun
    22 December 2016 - Confusion of Diclofenac Llorens° ampuls 75 mg / 3 mL with those of Metamizol Normon° 2 g / 5 mL and Flumil® 300 mg / 3 mL (acetylcysteine)
    12 October 2016 - Risk of dosage errors with Aspegic° injectable
    26 August 2016 - Risk of dosage errors with Nexavar° (sorafenib) tablets 200 mg
    5 August 2016 - Risk of inappropriate storage of vials Zerbaxa° 1 g / 0.5 g (ceftozolane / tazobactam)
    2 August 2016 - Continuing confusion between Alkeran° 2 mg (melphalan) and Leukeran° 2 mg (chlorambucil)
    1 August 2016 - Confusion between packages of Remifentanil Sala° vials 1 and 5 mg
    21 July 2016 - Risk of incorrect conservation Mekinist° 0.5 mg, 1 mg and 2 mg coated tablets (trametinib)

ISMP USA

February 5, 2021 - Updated ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations
ISMP’s list points out the error-prone abbreviations, symbols, and dose expressions included on The Joint Commission’s “Do Not Use” list, which must be included on an accredited organization’s “Do Not Use” list. Read on…

  • ISMP Medication Safety Alert! Acute Care edition
    The Acute Care edition newsletter has been in circulation since 1996. It is a compilation of medication and device related errors, prevention recommendations and editorial content. It alerts practitioners and managers in a timely fashion to potentially hazardous situations that may contribute to adverse drug events.
    Periodicity: biweekly
    Publication langage: English
    On subscription only. Sent by e-mail to subscribers.
    Access to ISMP Medication Safety Alert! Acute Care edition: Read on...
    Follow ISMP on Twitter

     

    What's new in the last issue?

    - Disrespectful Behavior in Healthcare: Has It Improved?
    - Safety briefs: Outsourced paralyzing agent packaging could pose a serious safety issue; Errata; More on fluorouracil and pets

  • ISMP Alerts
    In addition to a full suite of medication safety newsletters for healthcare professionals and consumers, ISMP makes available urgent medication advisories. These Safety Alerts address serious medication errors or information requiring immediate attention by healthcare practitioners.
    Periodicity: as needed
    Publication langage: English
    No Subscription.
    Access to ISMP Alerts: Read on...

     

    What are the last alerts?

    14 May 2021 - Barcode Scanning Error. Read on…
    27 January 2021 - HAZARDOUS SITUATION – PLEASE REACT IMMEDIATELY
    Certain Meitheal Pharmaceuticals cartons labeled properly as cisatracurium, but the vials within are mislabeled as phenylephrine but actually contain cisatracurium Read on…
    6 September 2018 - Check for Proper Nucala Dose Preparation Read on...
    24 April 2018 - Verapamil-Naloxone Look-Alike Vials Read on...
    23 April 2018 - Packaging Could Lead to Acetaminophen Overdoses Read on...

  • National Alert Network (NAN) Alert
    ISMP joined with the other members of the National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP) to create a National Alert Network (NAN) that broadens the reach of alerts. The NAN warns healthcare providers through several national distribution channels of the risk for medication errors that have recently caused serious harm or death.
    Periodicity: as needed
    Publication langage: English
    No Subscription. Available for free download or sent by e-mail to ISMP bulletins subscribers.
    Access to National Alert Network (NAN) Alert: Read on...

     

    What are the last alerts?

    September 9, 2020: Dangerous Wrong-Route Errors with Tranexamic Acid. Read on…
    May 24, 2018: Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages Read on...
    12 October 2017: Severe hyperglycemia in patients incorrectly using insulin pens at home Read on...
    15 September 2016: Observe for possible fluid leakage when preparing parenteral syringes Read on...
    30 June 2015 - Move toward full use of metric dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL Read on...
    23 March 2015 - Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection Read on...

  • ISMP Medication Safety Alert! Community/Ambulatory Care edition
    The Community/Ambulatory Care edition is targeted toward pharmacists, pharmacy technicians, nurses, physicians and other community health professionals. This newsletter provides timely information about medication-related errors and adverse drug reactions and their implications for community practice sites, and offers recommendations on how to improve medication safety within the community setting.
    Periodicity: montly
    Publication langage: English
    On subscription only. Sent by e-mail to subscribers.
    Access to ISMP Medication Safety Alert! Community/Ambulatory Care edition: Read on...

     

    What's new in the last issue?

    - Ensuring the Safe Use of Automated Dispensing Technology: We Need Your Input!
    - Close calls—a sign of resilience or vulnerability? Odds are higher that vulnerabilities are reported
    - Infection transmission risk with shared glucometers, fingerstick devices, and insulin pens
    - Safety briefs: Update on need for a pegfilgrastim formulation for pediatric dosing; Confusing syringe scale; Confirm correct mg and mL dose based on product concentration supplied; Confusing labeling on a two-dose blister

  • ISMP Medication Safety Alert! Long-Term Care Advise-ERR
    The Long-Term Care Advise-ERR is a newsletter specifically tailored to the long-term care setting, which provides timely medication safety information to staff working with resident populations that are often elderly, frail, dependent, complex in nature, and fraught with many different illnesses and dysfunctions.
    Periodicity: monthly
    Publication langage: English
    On subscription only
    Access to ISMP Medication Safety Alert! Long-Term Care Advise-ERR: Read on...

     

    What's new in the last issue?

    - Infection Transmission Risk with Shared Glucometers, Fingerstick Devices, and Insulin Pens
    - Close calls – a sign of resilience or vulnerability? Odds are higher that vulnerabilities are reported
    - what’s in a Name? The “-oxacin” drug name stem
    - Safety Wires: Zantac reborn; Medication reconstitution with cleaning products; Look-alike cartons for topical creams; Confusing syringe scale

  • ISMP Medication Safety Alert! Nurse Advise-ERR
    The Nurse Advise-ERR is designed to meet the medication safety information needs of nurses who transcribe orders, administer medications, and monitor the effects of medications on patients. The newsletter offers detailed error reports and checklists of evidence-based error reduction strategies.
    Periodicity: monthly
    Publication langage: English
    On subscription only
    Access to ISMP Medication Safety Alert! Nurse Advise-ERR: Read on...
    What's new in the last issue?

    - Infection Transmission Risk with Shared Glucometers, Fingerstick Devices, and Insulin Pens
    - How will PCA (patient controlled analgesia) be administered to patients during an MRI (magnetic resonance imaging)?
    - great catch: PRAXBIND label information needs repositioning
    - what’s in a Name? The “-begron” drug stem name
    - Safety Wire: Risks with leaving discontinued infusions connected to the patient

  • ISMP Safe Medicine
    Safe Medicine is the US consumer health education newsletter that focuses specifically on the prevention of medication errors. This ISMP newsletter teaches consumers to become active partners with their healthcare providers and assume a leading role in ensuring safe medication use.
    Periodicity: bimonthly
    Publication langage: English
    On subscription only
    Access to ISMP Safe Medicine: Read on...
    What's new in the last issue?

    - Parents Staying with Their Hospitalized Child Can Help Detect Some Errors – But May Contribute to Others
    - Do not use ivermectin to treat or prevent coronavirus disease 2019 (COVID-19)
    - Advice from FDA: Vapors from alcohol-based hand sanitizers can have side effects
    - Get your annual flu shot now

  • ISMP Safety Video Newsletter Series
    October 15, 2017 - Episode #3
    April 1st, 2017 - Episode #2
    July 1st, 2016 - Episode #1
 
  • Regular columns in professional journals
    Hospital Pharmacy

    Hospital Pharmacy is an independent, peer-reviewed journal, practitioner-focused and dedicated to the promotion of best practices and medication safety. This seminal column hosted since 1975 by Hospital Pharmacy was the first regular publication on medication errors analysis and prevention.
    Periodicity: monthly with the exception of a combined July/August issue
    Publication langage: English
    Access to ISMP Medication Error Report Analysis in Hospital Pharmacy: Read on...

    Journal of Emergency Nursing

    The Journal of Emergency Nursing is the official peer-reviewed journal of the Emergency Nurses Association (ENA), reaching emergency nurses, emergency/trauma departments and emergency department managers.
    Publication langage: English
    Access to Danger Zone column in Journal of Emergency Nursing: Read on...

    Pharmacy Times

    Pharmacy Times is a clinically-based, monthly journal providing practical information pharmacists can use in their everyday practice.
    Periodicity: monthly
    Publication langage: English
    Access to Medication Safety column in Pharmacy Times: Read on...

ivm Voorkomen Medicatie-Incidenten (VMI)

  • VMI Praktijkprikkel
    A dynamic way on involving healthcare practitioners into patient safety attention so-called “Practice Stings”, meaning incentives about practice. With the consent of the reporter, case reports are presented with a short analysis. The described problem, selected by the possibility to occur at other organizations, is submitted to a specific survey on the problem and ways of preventing it. Its purpose is to raise awareness in other organizations and to stimulate them to consider in their own work environment what precautions are needed to prevent a similar incident from occurring.
    Periodicity: as needed
    Publication langage: Dutch, English translation since September 2021
    No Subscription. Available for free download or sent by e-mail to registered users.
    Access to VMI Praktijkprikkel: Read on (in Dutch)...

    Follow ivmVMI on Twitter

    What are the last VMI Praktijkprikkel?

    16 September 2021 - Praktijkprikkel 2021-18: Importance of derived contraindication in medication monitoring Read on...
    2 September 2021 - Praktijkprikkel 2021-17: Prescribing medication for the unborn child Read on...
    17 August 2021 - Praktijkprikkel 2021-16: Discharge medication around the weekend
    3 August 2021 - Praktijkprikkel 2021-15: Unclear control over the treatment
    21 July 2021 - Praktijkprikkel 2021-14: Hepatitis B vaccine interchangeability
    7 July 2021 - Praktijkprikkel 2021-13: Insufficient control of a running infusion
    23 June 2021 - Praktijkprikkel 2021-12: Risky to substitute two insulins at the same time by biosimilar preferential products
    8 June 2021 - Praktijkprikkel 2021-11: Confusion between drugs containing estradiol/norethisterone 2mg/1mg
    25 May 2021 - Praktijkprikkel 2021-10: Confusion between Humalog° and Lyumjev°
    12 May 2021 - Praktijkprikkel 2021-09: Dosing incidents with Oramorph°
    21 April 2021 - Praktijkprikkel 2021-08: An error often does not stand alone
    9 April 2021 - Praktijkprikkel 2021-07: (Near) errors after not performing a double check when preparing medication for administration
    24 March 2021 - Praktijkprikkel 2021-06: Crushing high-risk drugs
    10 March 2021 - Praktijkprikkel 2021-05: Dual anticoagulation with no expected duration of treatment
    24 February 2021 - Praktijkprikkel 2021-04: Contraindication bariatric surgery
    10 February 2021 - Praktijkprikkel 2021-03: Incorrect start date of an Individualized Distribution System (GDS)
    27 January 2021 - Praktijkprikkel 2021-02: Opioids and laxatives
    12 January 2021 - Praktijkprikkel 2021-01: Electronically prescribing nasal sprays. Results of the survey published March 2021
    23 December 2020 - Praktijkprikkel 202O-19: Mix-ups between Fraxiparine° and Fraxiparine Forte°
    9 December 2020 – Praktijkprikkel 202O-18: Back to the “old” normal practices used before Covid-19 pandemic
    25 November 2020 - Praktijkprikkel 202O-17: Confusion in the dosage of nystatin in the patient leaflet
    November 2020 - Praktijkprikkel 202O-16: Allergen extracts
    28 October 2020 - Praktijkprikkel 202O-15: Imported medicines: mix-up between acenocoumarol 1mg and imported Sintrom° 4 mg tablets
    16 October 2020 - Praktijkprikkel 202O-14: Amoxicillin and allergy
    17 September 2020 - Praktijkprikkel 202O-13: Unclear dosage of prescribed imipenem / cilastatin
    September 2020 - Praktijkprikkel 202O-12: Incorrectly entered height and underdosing of cytostatics
    August 2020 - Praktijkprikkel 202O-11: Incidents related to the use of syringe pumps
    July 2020 - Praktijkprikkel 202O-10: Feedback of medication change message and the delivery confirmation to the doctor
    7 July 2020 - Praktijkprikkel 202O-09: Risk with an individualized administration plan. Results of the survey published July 2020
    June 2020 - Praktijkprikkel 202O-08: Risks with repeat service
    28 May 2020 - Praktijkprikkel 202O-07: Dealing with prescriptions for non-everyday medicines
    7 May 2020 - Praktijkprikkel 202O-06: Barcode final check and change of medication
    April 2020 - Praktijkprikkel 202O-05: Partial delivery of high-risk medication due to drug shortages
    31 March 2020 - Praktijkprikkel 202O-04: Mix-up between two forms of benzylpenicillin: sodium benzylpenicillin and benzathine benzylpenicillin
    20 February 2020 - Praktijkprikkel 202O-03: Dosing advice based on incorrectly entered value
    6 February 2020 – Praktijkprikkel 202O-02: Starter packaging of direct oral anticoagulants
    20 January 2020 – Praktijkprikkel 202O-01: Discharge discrepancies with automated medication dispensing

Morocco Poison Control and Pharmacovigilance Centre (CAPM)

  • Toxicologie Maroc
    Periodicity: four to six issues annually
    Publication langage: French
    No Subscription. Available for free download
    Access to Toxicologie Maroc: Read on (in French)...

     

    What's new in the last issue?

    - Azithromycin related errors in Covid-19 patients
    - Be careful of the risks of using vitamin d in children for Covid-19 prevention

  • Regular columns in professional journals
    Doctinews

    Publication langage: French
    Access to the "Live from CAPM" column in Doctinews: Read on (in French)...

New Zealand Medication Safety Programme

  • Medication Safety Watch
    Medication Safety Watch is a bulletin for all health professionals and health care managers working with medicines or patient safety. Medication alerts and safety signals provide information and actions about high-risk medicines and situations. They are issued to health care staff, managers and organisations.
    Periodicity: four issues by year
    Publication langage: English
    No subscription. Available for free download.
    Access to Medication Safety Watch: Read on...

     

    What's new in the last issue?

    - Reducing the risk of error and patient harm with low-dose oral methotrexate
    - What’s new? Update on the safe use of opioids collaborative; Making strong opioids safer for patients
    - What to do with patients' own medicine in hospital?
    - Incidents and cautions: Sodium citrate or sodium chloride?
    - Upcoming alert: a draft alteplase/tenectaplase alert will be sent out in the near future

  • Alerts & Patient Safety Signal
    The alerts produced by the Commission are recommendations relating to either internationally recognised or locally identified high risk medicines or situations. Alerts are sent out directly to relevant health care providers with the latest information and advice on particular topics of concern.
    Periodicity: as needed
    Publication langage: English
    No Subscription. Available for free download or sent by e-mail to registered users.
    Access to Alerts & Patient Safety Signal: Read on...

     

    What's the last Alert or Safety Signal?

    26 September 2019 - Transdermal patch alert updated Read on…
    13 Mar 2019 - Changes to the labelling of Bicillin LA° Read on...
    19 July 2017 - Open Book ALERT: Prescribing error – dabigatran and enoxaparin Read on...
    6 July 2017 - Transdermal patches and burns: Commission’s transdermal patch medication Alert 15 published in 2013, updated list of transdermal patches available in New Zealand (June 2017) Read on...
    6 July 2017 - Injectable phenytoin incidents – risk of death and severe harm Read on...
    12 June 2017 - ALERT 17: Alteplase or tenecteplase? Read on...
    24 February 2017 – Pharmacy Council Safety Alert - Caution Required with Compounded Oral Liquid Formulations Read on…
    30 September 2015 - Safety Signal: Risk of serious adverse drug reactions Read on...
    3 September 2014 - ALERT: Transdermal patches Read on...
    5 August 2014 - ALERT: Metoprolol Read on...

NHS England

  • Patient Safety Alerts
    Patient safety alerts are issued via the Central Alerting System (CAS), a web-based cascading system for issuing alerts, important public health messages and other safety critical information and guidance to the NHS and other organisations, including independent providers of health and social care.
    Periodicity: as needed
    Publication langage: English
    No subscription. Available for free download.
    Access to NHS England Patient Safety Alerts: Read on...

     

    What are the last medication safety alerts?

    25 August 2021 - Elimination of bottles of liquefied phenol 80% Read on…
    14 July 2021 - Inappropriate anticoagulation of patients with a mechanical heart valve. Read on…
    14 June 2021 - Letter to women and girls taking sodium valproate. Read on…
    6 August 2020 - Risk of death from unintended administration of sodium nitrite Read on…
    1st April 2020 - Interruption of high flow nasal oxygen during transfer Read on…
    28 November 2019 - Risk of death and severe harm from ingesting superabsorbent polymer gel granules. Read on…
    5 November 2019 - Depleted batteries in intraosseous injectors Read on…
    9 August 2018 - Resources to support safe and timely management of hyperkalaemia. Read on…
    17 April 2018 - Risk of death or severe harm from inadvertent intravenous administration of solid organ perfusion fluids Read on...
    9 January 2018 - Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders Read on... (Updated on 19 June 2018)
    9 November 2017 - Confirming removal or flushing of lines and cannulae after procedures Read on...
    27 September 2017 - Risk of severe harm and death from infusing total parenteral nutrition too rapidly in babies Read on... (Updated on 6 March 2019) Read on...
    11 August 2017: Resources to support safe transition from the Luer connector to NRFit for intrathecal and epidural procedures, and delivery of regional blocks Read on...
    5 July 2017 - Risk of death and severe harm from ingestion of superabsorbent polymer gel granules Read on...
    6 April 2017 - Supporting the safety of girls and women being treated with valproate Read on...
    16 November 2016 - Risk of severe harm and death due to withdrawing insulin from pen devices Read on...
    9 November 2016 - Risk of death and severe harm from error with injectable phenytoin Read on...
    3 October 2016 - Reducing the risk of oxygen tubing being connected to air flowmeters Read on...
    7 September 2016 - Restricted use of open systems for injectable medication Read on...
    17 August 2016 - Resources to support the care of patients with acute kidney injury Read on...
    20 April 2016 - Patient safety incident reporting and responding to Patient Safety Alerts Read on...
    8 February 2016 - Risk of severe harm or death when desmopressin is omitted or delayed in patients with cranial diabetes insipidus Read on...
    26 October 2015 - Support to minimise the risk of distress and death from inappropriate doses of naloxone Read on...
    18 August 2015 - Addressing antimicrobial resistance through implementation of an antimicrobial stewardship programme Read on...
    27 May 2015 - Risk of death or severe harm due to inadvertent injection of skin preparation solution Read on...
    1st April 2015 - Managing risks during the transition period to new ISO connectors for medical devices Read on...
    19 January 2015 - Harm from using Low Molecular Weight Heparins when contraindicated Read on...

Prescrire


Prescrire provides independent information, by and for healthcare professionals, about drugs and therapeutic and diagnostic strategies. A non-profit organisation, Prescrire is wholly financed by its subscribers, and accepts no advertising or other outside support. Read on...

Covid-19 : Follow Prescrire's independent, evidence-based analysis of the pandemic.
Prescrire's editors are publishing an ongoing series of news updates featuring independent analysis of developments related to the covid-19 pandemic. Read on…

  • Prescrire International
    Periodicity: 11 times a year
    Publication langage: English
    On subscription only, offering full access online to the entire database of reviews in English going back to the first issue of Prescrire International in 1992.
    Access to Prescrire International: Read on...
    From the editors of Prescrire International: "Top Texts of 2020" new sampling of texts selected to introduce to Prescrire International Free Special Edition
    Already subscriber? Refer a friend or colleague Become an ambassador

     

    What's new in the last issue?

    - Preventable deaths (Editorial) Could this have been caused by a drug? Many deaths are never attributed to the drug responsible, while many are preventable by various means, within easy reach. Read on…
    - Drug-induced QT prolongation, torsade de pointes and sudden cardiac death. Known effects that are therefore preventable, which call for caution when choosing a drug of this type, and careful monitoring of treatment. Read on…
    - Stopping antidepressant therapy. Plan tapered withdrawal. When available, oral solutions facilitate tapered withdrawal, provided the patient understands how to use the dosing device. Read on…
    - Drug packaging, a key factor of quality that sometimes determines the choice of a medicinal product: 2020 review. Pharmaceutical companies and drug agencies still have a long way to go in protecting patients and their families from the dangers of poor-quality drug packaging. Read on…

  • La revue Prescrire
    Periodicity: monthly plus a yearly supplement in French devoted to drug interactions
    Publication langage: French
    On subscription only, offering full access online to the entire database of reviews going back to the first issue of La revue Prescrire in 1981.
    Access to La revue Prescrire: Read on (in French)...
    Follow La revue Prescrire on Twitter

    What's new in the last issue?

    - Fair value (Editorial) To prevent medication errors, it is up to the companies to produce safe packaging from the onset and for the agencies to be uncompromising on this point. Read on (in French)…
    - Nasal Glucagon (Baqsimi°) and hypoglycemia with loss of consciousness. Convenient when the patient's entourage is not comfortable with injections, but does not exempt from teaching how to use it beforehand. Read on (in French)…
    - Lacosamide (Vimpat°) for the prevention of generalized epileptic seizures, from the age of 4 years. The packaging of the syrup always exposes to preparation errors
    -  Oral typhoid vaccine (Vivotif°). Gastroresistant capsules not to be opened and a live vaccine, to be avoided in pregnant women, in cases of immunosuppression, acute febrile syndrome or acute gastrointestinal disease
    - Lidocaine ophthalmic gel (Ophtesic°) and ocular anesthesia. A welcome new presentation that eliminates the risky off-label use of urethral syringes
    - Budesonide 100 microg + formoterol 3 microg (Symbicort Rapihaler°). Within the Symbicort° range, different dosage combinations and two different inhaler devices are confusing
    - Sinemet° (levodopa + carbidopa) tablets: the imbroglio of bars! No-function bar for sustained-release tablets that must not be cut: confusing for patients and their families, but also for caregivers
    - Teriparatide in pens or cartridges: multidose presentations not to be drawn with a syringe. To avoid injecting the entire contents of the pen or cartridge, ensure that the patient is supplied with the correct pen needles and pen for their cartridges
    - Rotarix° oral vaccine: presentation in flexible tube. Welcome, but late, replacement of the syringe-like device that led to erroneous intramuscular or subcutaneous injections
    - Cabazitaxel copied: beware of dose errors. Risk of error due to differences in dosage form, strength, concentration or method of preparation between copies and Jetvana°
    - Last minute - Amitriptyline oral (Laroxyl°): return of the dropper! A surprising and unexplained turnaround after the welcome replacement of a dosing syringe graduated in mg yet more accurate
    - Echoes of Practice Matters (A Prescrire’s CE programme) - Cleaning up. Systematically think about the possibility of pregnancy
    - Subscribers' Mail – Forget. In search of the lost Calciparin° dose: so many interruptions in work that could have led to an omission

Updated on September 20, 2021