Post date: 5 days 17 hours ago

ISMP has received multiple reports recently about fentaNYL patches being inappropriately prescribed for opioid-naïve, elderly patients upon discharge from a hospital and transfer to a long-term care facility. This week’s ISMP newsletter featured article presents recommendations for system safeguards to avoid the risk of patient harm. For more, see:

Post date: 1 week 13 hours ago

Due to the COVID-19 pandemic, our survey on the level of implementation of the two new 2020-2021 Targeted Medication Safety Best Practices (TMSBPs) for Hospitals was put on hold. As crisis mode begins to diminish, we would appreciate your participation in this survey regardless of whether you have implemented the Best Practices.. The survey is available at: and will be open through July 17, 2020. Since we are only conducting the survey on the two new Best Practices, it should only take you about 5 minutes to complete. You can view all the TMSBPs by going to:

Post date: 1 month 2 days ago

Due to shortages of neuromuscular blocking agents needed for critically ill COVID-19 patients, the FDA has allowed temporary manufacture of these drugs without the usual statement: “Warning: Paralyzing Agent” on the vial cap. The lack of a warning statement may make vials look similar to other medications and lead to possible confusion and errors. For ISMP recommendations to avoid mix-ups and ensure safe storage, visit:

Post date: 1 month 3 days ago

A single strategy, particularly one as weak as education alone, is rarely enough to change behaviors and prevent medication errors. Instead, numerous high-leverage risk-reduction strategies than improve system reliability must be layered together to create a more robust safety system. For more on education’s weaknesses as an intervention and a list of key ISMP strategies for improvement, see the latest ISMP newsletter featured article:

The mission of the Medication Safety Officers Society (MSOS) is to advance and encourage excellence in safe medication use by providing communication, leadership, direction, and education among its members.