ISMPMedicationSafetyAlert.docVIP

One of the most important ways to prevent medication errors is to learn about problems that have occurred in other organizations and to use that information to prevent similar problems at your practice site. To promote such a process, the following selected items from the April—June 2016 issues of the ISMP Medication Safety Alert! have been prepared for an interdisciplinary committee to stimulate discussion and action to reduce the risk of medication errors. Each item includes a brief description of the medication safety problem, a few recommendations to reduce the risk of errors, and the issue number to locate additional information as desired. Look for our high-alert medication icon under the issue number if the agenda item involves one or more medications on the ISMP List of High-Alert Medications (/sc?id=479). The Action Agenda is also available for download in a Microsoft Word format (/newsletters/acutecare/articles/ActionAgenda1603.doc) that allows expansion of the columns in the table designated for organizational documentation of an assessment, actions required, and assignments for each agenda item. Continuing education credit is available for nurses at: /sc?id=480. Key: — ISMP high-alert medication No. Problem Recommendation Organization Assessment Action Required/ Assignment Date Completed Reassess the safety of neuromuscular blockers in your facility (12) Serious events continue to occur with neuromuscular blocking agents in the operating room, emergency department, critical care and medical-surgical units, and other patient care locations, including interventional radiology departments. Many of the harmful or fatal errors involve the accidental administration of a neuromuscular blocker when another drug is intended. These errors are caused by look-alike drug names, packaging, and labeling; unlabeled or mislabeled syringes; unsafe storage; knowledge deficits; and other causes. Special attention should be given to proper ordering, storage, selec