ISMP Reports – Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020

1Prescribing, dispensing, and administering extended-release (ER) opioids to opioid-naïve patients
2Not using smart infusion pumps with dose error-reduction systems (DERS) in perioperative settings
3Errors with oxytocin
4Hazards associated with positioning infusion pumps outside of COVID-19 patients’ rooms
5Errors with the COVID-19 vaccines
6Use of the retrospective, proxy “syringe pull-back” method of verification during pharmacy sterile compounding
7Combining or manipulating commercially available sterile products outside the pharmacy
8Medication loss in the tubing when administering small-volume infusions via a primary administration set
9Wrong route (intraspinal injection) errors with tranexamic acid
10Use of error-prone abbreviations, symbols, or dose designations

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