ISMP: Top 10 medication errors and hazards in 2019

January 21, 2020

As reported to the The Institute for Safe Medication Practices (ISMP).

The Institute for Safe Medication Practices (ISMP) released its list of the top 10 most persistent medication errors and safety issues of 2019 last week.

A copy of the newsletter can be found here.

In their newsletter, ISMP says that they believe the issues merit attention and priority if action has not already been taken to mitigate risk. The Institute also says they hope that the hazards and errors listed in the slides below become an essential part of healthcare organizations’ strategic medication safety improvement plans in 2020.Â

Top 10 medication safety errors and hazards of 2019

10. 1,000-fold zinc overdoses

9. Unsafe use of syringes for vinca alkaloids

8. Unsafe labeling of profiled syringes and infusions by 205b compounders

7. Wrong route (intraspinal injection) errors with tranexamic acid

6. Unsafe practices associated with IV push medications. In 2019, ISMP conducte

5. Unsafe “overrides” with automated dispensing cabinets (ADCs)

Click here for ISMP's ADC guidelines outlining standard best practices and processes.

4. Misheard drug orders or recommendations during verbal/telephone communication

3. Errors and hazards due to look-alike labeling

2. Daily, instead of weekly, oral methotrexate for non-oncologic conditions

1. Selecting the wrong medication after entering the first few letters of the dr