R E V I E W S & A N A LY S E S Medication Errors Involving Healthcare Students Liz Hess, PharmD, MS INTRODUCTION Patient Safety Analyst Nursing, pharmacy, medical, and other healthcare students have a large presence in Michael J. Gaunt, PharmD U.S. hospitals while they engage in clinical experiences to meet the requirements of Sr. Medication Safety Analyst Matthew Grissinger, RPh, FISMP, FASCP their professional education and learn the principles of clinical practice. Direct patient- care experiences are vital for students to prepare for the real world.1-2 This hands-on Manager, Medication Safety Analysis experience places them in a position to be involved in errors as well as catch potential Pennsylvania Patient Safety Authority or actual errors. Nursing student errors remain largely unreported,3 potentially because of fear of liability.4 The literature about nursing student errors focuses predominantly ABSTRACT on the student’s ability to perform calculations and numeracy skills, rather than a Students acquire vital clinical experience broader range of practical clinical skills.1,4 Literature focusing on pharmacy students while participating in patient care, but discusses prevention of medication errors.5 There is little information on other health- they can become involved in medica- care student involvement in medication-related events and even less literature about tion errors. The extent of this problem is students preventing errors. relatively unexplored. Analysts reviewed Pennsylvania is home to 85 nursing programs, 7 pharmacy schools, and 7 medical medication-error events mentioning schools.6,7,8 Students from these schools, as well as students from other states, will be students submitted to the Pennsylvania involved in the medication-use process. Students ranging in experience from first-year Patient Safety Authority from July 2010 healthcare students to students in their final year before graduation will be involved, through June 2015. Of the 711 events either directly or indirectly, in the care of patients in Pennsylvania. Pennsylvania identified, 87.3% (n = 621) reached Patient Safety Authority analysts have not previously explored the role students play in the patient. Analysts also found that stu- contributing to and intercepting medication errors reported through the Authority’s dents caught or discovered the error in Pennsylvania Patient Safety Reporting System (PA-PSRS). This analysis identified 16.2% (n = 115) of reports. The most events that mention the involvement of students, including those that reached the common node of origin for the medica- patient, and some in which the student detected the error. tion error was administration (75.9%, n = 540). The most common event METHODS types were extra dose (16.6%, n = 118), dose omission (13.2%, Analysts queried the PA-PSRS database for medication errors that occurred from July n = 94), and wrong time (11.4%, 2010 through June 2015 that included the word “student” in the narrative. This query n = 81). High-alert medications, includ- yielded 808 event reports. Events that included students but also mentioned that the ing insulin, opioids, and anticoagulants, instructor was involved in an error were included in the analysis. In this context, an were reported in 40.9% (n = 291) instructor is defined as the healthcare professional overseeing the student’s work while of events. Professional organizations, in the hospital, whether school faculty or an on-site preceptor.9 Event reports that men- healthcare facilities, and professional tioned students, but indicated that the student was not involved in the error (e.g., the schools can help reduce the risk of patient woke up while student was in the room) were excluded, leaving 711 reports for student-involved errors by implementing analysis. The medication name, route of administration, patient care area, and harm key strategies, including incorporation score, adapted from the National Coordinating Council for Medication Error Reporting of didactic and experiential medication and Prevention (NCC MERP) harm index,10 were provided by the reporting facility. safety content into school curricula and When a medication-name data field was left blank but the name was provided in the on-site training programs. (Pa Patient event description, an analyst adjusted the medication name field. The reports were Saf Advis 2016 Mar;13[1]:18-23.) evaluated to determine the factors associated with medication errors involving students. Analysts classified reports by the type of student involved, node of origin, presence of Corresponding Author the instructor, and whether the student caught or was involved in the error. Analysts Matthew Grissinger made note of events involving high-alert medications, based on the Institute for Safe Medication Practices (ISMP) List of High-Alert Medications in Acute Care Settings.11 RESULTS Reports were categorized by harm score; 87.3% (n = 621) of the events reached the patient (harm score = C through I) and only 0.6% (n = 4) of the events resulted in patient harm (harm score = E through F; no events with harm scores G, H, or I were reported; see Figure 1). Overall, 63 unique patient care areas were associated with Page 18 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority Figure 1. Harm Scores for Student-Related Medication Errors, as Reported to the Student gave medication at Pennsylvania Patient Safety Authority, July 2010 through June 2015 (N = 711) 4:30 p.m. (4 p.m. scheduled dose); NUMBER OF REPORTS however, was unaware that the Reports of events that did medication was given previously at 450 420 not reach the patient 3:30 p.m. causing the next dose (due 400 (12.7%, n = 90) at 10 p.m.) to appear as given as 350 an off schedule dose. Student nurse Reports of events that and instructor relied on paper MAR 300 reached the patient [medication administration record], 250 (87.3%, n = 621) which did not reflect medication 197 signed off as given, without checking 200 the computer system to determine if 150 medication had previously been given. Upon further investigation, found 100 57 students do not have access into the 50 29 computer system, they work directly 4 3 1 0 0 0 under the supervision of their instruc- 0 A B1 B2 C D E F G H I tor. Physician notified of incident, patient’s vital signs assessed, orders Incident (99.4%, n = 707) Serious Event (0.6%, n = 4) MS16134 reviewed, 10 p.m. dose of medication held. No harm reached the patient. HARM SCORE The nurse was precepting a nursing Table 1. Care Areas Most Commonly Reported in Student-related Medication Errors, as student. The nurse handed the stu- Reported to the Pennsylvania Patient Safety Authority, July 2010 through June 2015 (N = 711) dent a 30-unit insulin syringe. After seeing this syringe, the student indi- CARE AREA NO. OF REPORTS % OF REPORTS cated that he gave the prior patient Medical/Surgical unit 203 28.6 the wrong dose using a 100-unit Telemetry 87 12.2 syringe. The student had adminis- tered 90 units instead of 9 units. Medical unit 48 6.8 The attending physician was noti- Medical/Oncology unit 25 3.5 fied; ordered IV [intravenous] fluids Emergency department 23 3.2 with dextrose and hourly finger-stick glucose checks. Orthopedic unit 22 3.1 Instructor and student nurse Medical/Surgical/Oncology unit 20 2.8 administered a dose of Neurontin® Cardiac unit 20 2.8 [gabapentin] 400 mg to the wrong Pharmacy 19 2.7 patient. Attending physician alerted. Per the student nurse and instructor, Pediatric unit 19 2.7 name band checked. All other care areas 225 31.6 High-alert medications pose an increased risk of patient harm when involved in student-involved events and event reports; wrong time (11.4%, n = 81), wrong dose/ medication errors.11 High-alert medica- the most common areas are shown in overdosage (9.8%, n = 70), and wrong tions were reported in 40.9% (n = 291) of Table 1. The most common nodes of ori- patient (5.9%, n = 42). Following are exam- events. Insulin (33.3%, n = 97), opioids gin for the reported events, as identified ples of extra dose, wrong dose/overdosage, (24.1%, n = 70), and anticoagulants by the analysts, are shown in Figure 2. and wrong patient event reports:* (15.8%, n = 46) were the three most common drug classes involved in events. The most common types of events reported * The details of the PA-PSRS event narratives These three classes represented 73.2% by facilities were extra dose (16.6%, in this article have been modified to preserve (n = 213 of 291) of all events involving a n = 118), dose omission (13.2%, n = 94), confidentiality. Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 19 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S high-alert medication (see Figure 3, avail- Figure 2. Nodes of the Medication-Use Process in Which Student-Related Medication able exclusively online with this article Errors Originated, as Identified in Events Reported to the Pennsylvania Patient Safety Authority, July 2010 through June 2015 (N = 711) at http://patientsafetyauthority.org/ ADVISORIES/AdvisoryLibrary/2016/ 7.7% 8.6% Mar;13(1)/Pages/home.aspx) and 30.0% n = 55 n = 61 2.7% (n = 213 of 711) of all reported events. n = 19 More than two-thirds (69.8%, n = 496) of reported events occurred during peak 5.1% n = 36 academic periods — February, March, and April and September, October, and November (see Figure 4). Prescribing The majority of students involved in errors were nursing students (see Table 2). Nearly Transcribing 4% (n = 28) of reports did not involve Dispensing students, but rather involved instructors. Following are examples of events involv- Administering ing instructors and nursing or pharmacy Monitoring students: Nursing instructor removed the 75.9% wrong patient’s medication and tub- n = 540 ing from the patient medication bin, MS16135 and the student nurse scanned the dose [barcode], flushed the syringe pump tubing, and connected the Rocephin® (cefTRIAXone) dose to communicate that she received dupli- in the error, the instructor or precep- the IV. Instructor noted the wrong cate medications. tor was noted to be involved or present patient name on another medication 28.9% of the time (n = 164 of 568). In removed from bin and stopped the Patient told pharmacy student that she was taking fluticasone nasal the subset of nursing students, instructors Rocephin [infusion]. Syringe pump were commonly present when these stu- with wrong tubing was running for spray. Pharmacy student accidentally logged fluticasone as fluticasone dents were involved in medication errors approximately two to three minutes (92.1%, n = 151 of 164). When a student at 0.3 mL/min before being stopped 50 mcg inhalation powder instead of the nasal spray. Student was was found to be involved in the error, the and the correct tubing applied. Both most common node in which the event patients were receiving same dose unaware that there is an inhaler and nasal spray both with a 50 mcg originated was administration (84.2%, of Rocephin. n = 478 of 568) followed by monitoring strength. Student picked the first One Percocet® [oxyCODONE and 50 mcg product she saw. When the (8.5%, n = 48). Following are examples of acetaminophen] tablet was given to physician reconciled [the patient’s reports of student-involved events: the wrong patient by an unattended medications], because fluticasone Patient received medication in error. nursing student. Physician notified. inhaler is not a formulary item, Medication was ordered for another Medication policy was reviewed with the physician chose a therapeutic ED patient. Patient medicated the student nurses. alternative of Flovent® [fluticasone improperly by nursing student work- Primary nurse administered the propionate] 220 mcg/inhalation ing under this RN’s supervision. patient’s 10 a.m. medications [and BID. Pharmacist caught error when Nursing student documented giving did not complete] computer documen- she was reviewing medication history oxyCODONE but the documen- tation that this occurred. Student for another issue. tation was not co-signed by the nurse assigned to the patient admin- Students were involved in the medication instructor. When this occurs, no istered 10 a.m. medications. The error in 79.9% (n = 568 of 711) of the one can document medications patient was confused and unable to events. When a healthcare professional on that order. There was a delay student was found to have been involved Page 20 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority Figure 4. Student-Related Medication Error Events by Month, as Reported to the wrong dose was on the previously Pennsylvania Patient Safety Authority, July 2010 through June 2015 (N = 711) administered meropenem dose. Events that occurred outside of Patient who was on peritoneal dialy- primary academic calendar periods sis was started on enoxaparin 30 mg NUMBER OF REPORTS (30.2%, n = 215) q12. The pharmacy reviewed and 120 Events that occurred during approved this dose. A pharmacy primary academic calendar periods (69.8%, n = 496) student was on the team and identi- 97 100 91 fied the dosing error prior to the 84 87 81 patient getting the second dose and 80 therefore the patient received the appropriate amount based on renal 56 status. Patient had no harm. 60 45 44 39 DISCUSSION 40 34 26 27 Although healthcare students may not intend to harm a patient, they are some- 20 MS16137 times involved in medication errors that require intervention. Reid-Searl et al. 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec validated that almost one-third of nursing MONTH students reported involvement in a near miss or actual medication error.3 A study Table 2. Type of Student Identified in Student-related Medication Error Reports, as Reported published in 2006 by Wolf et al. examin- to the Pennsylvania Patient Safety Authority, July 2010 through June 2015 (N = 711) ing data reported to MEDMARX®, the TYPE OF STUDENT NO. OF REPORTS % OF REPORTS* U.S. Pharmacopeia’s (USP’s) medication- error reporting database, found fewer Nursing 597 84.0 than 3% of errors involving students Pharmacy 44 6.2 resulted in patient harm and 2.1% of student nurses’ errors resulted in patient Medical 21 3.0 harm.4 This is similar to the finding Other students 21 3.0 herein that 0.6% (n = 4) of reported Not a student 28 3.9 errors caused patient harm. (i.e., instructor or preceptor) The level and depth of a student’s experi- *Does not equal 100 because of rounding. ence and academic preparation may play a role in some of the events reported in documenting the next dose of Following are examples of events caught to the Authority. It has been reported oxyCODONE. or discovered by students: that students’ inexperience and distrac- Of note, analysts identified that students MetroNIDAZOLE 500 mg IV tions contribute to medication errors.4,12 caught or discovered the error in 16.2% q8h order not profiled by phar- Students have also reported being (n = 115 of 711) of reports. Most errors macy on the [appropriate] therapy inadequately prepared for medication were caught by nursing students (60.9%, order. Missed order recognized by administration.13 n = 70 of 115), followed by pharmacy medical student while pre-rounding The number of error reports mention- students (33.0%, n = 38; see Figure 5, on patient. Medical student ing students was higher in the months available exclusively online with this arti- notified pharmacy of error and of February, March, and April as well cle at http://patientsafetyauthority.org/ MetroNIDAZOLE order was as September, October, and November. ADVISORIES/AdvisoryLibrary/2016/ promptly profiled. These three-month time periods coincide Mar;13(1)/Pages/home.aspx). Analysts Nursing student was preparing to with the academic calendar. identified that the most common nodes hang meropenem dose and noticed of origin for student-caught errors were It is standard for healthcare students to that the wrong patient name and prescribing (35.7%, n = 41) and admin- be overseen by faculty or preceptors dur- istering (32.2%, n = 37; see Figure 6). ing their clinical experiences.2,14 However, Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 21 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 6. Medication-Use Process Node in Which Student-Caught Medication Errors the involvement of pharmacy students in Originated, as Identified in Reports Submitted to the Pennsylvania Patient Safety catching errors.5 On an internal medicine Authority, July 2010 through June 2015 (N = 115) service, pharmacy students clarified 67% of orders with a medication or dose omis- Prescribing sion.5 In the data set analyzed for this 6.1% Transcribing article, analysts identified that students, n=7 Dispensing including nursing, pharmacy, and medical students, caught the error in 16.2% Administering (n = 115 of 711) of reports. 35.7% Monitoring To address students’ involvement in n = 41 32.2% medication errors and error prevention, n = 37 one institution provided students with a “Medication Safety Day.” Nursing stu- dents received education on causes of medication errors, along with awareness of the numerous contributing factors 7.8% in such errors.17 This initiative aimed 18.3% n=9 to raise awareness of causes and risk of n = 21 medication errors, along with prevention MS16139 strategies among student nurses.17 Limitations Reid-Searl et al. reported in 2010 that between students, nursing instructors, The retrospective review of reported errors many students do not receive appropri- and facility staff needs to be planned is limited by the information reported ate supervision while performing clinical carefully to ensure a model that considers through PA-PSRS, including the event responsibilities.3 The same study reported the safety hazards associated with dual descriptions and explanations. As with all that preceptors cannot always be physi- assignments.15 reporting systems, the type and number cally present with a student because they of reports collected depend on the degree Numerous additional conditions exist in supervise multiple students. When the to which facility reporting is accurate and the hospital setting that may contribute preceptor is with another student, the complete. The reporting cultures and to medication errors involving students. responsibility of supervision often falls to patterns in each facility, and their interpre- A few include communication and the staff nurse.3 This responsibility, added tations of what occurrences are reportable, documentation issues, monitoring issues, to typical patient care responsibilities, may can lead to reporting variations. preparing drugs for multiple patients, create situations in which direct student and medication administration records supervision may not be realistic. Even RISK REDUCTION STRATEGIES (MARs) not referenced.12,15-16 Improper though medication errors have occurred or limited access to the electronic health Professional organizations, healthcare when the preceptor is in the room with record (EHR) may limit students’ ability facilities, and professional schools can the student, medication errors are more to read about or document patient-care strive to identify system-based causes of likely to occur when the proper supervi- activities. Inconsistent use of the MAR, errors involving healthcare students and sion is not provided.3 whether due to limited access or other rea- instructors and implement effective types Patients who are assigned to student sons, can introduce risk when preparing of risk-reduction strategies to prevent nurses are also assigned to staff nurses; and administering medications.15 Because harm to patients. Consider the strate- these dual assignments can cause con- of a lack of experience, knowledge, or gies described below, which are based fusion. Communication breakdowns guidance, students may not be aware of on a review of current literature, events regarding who will administer the pre- vital signs or laboratory values that must reported to the Authority, and observa- scribed medications, what medications be checked prior to administering or veri- tions from ISMP. have been administered, and which fying a medication. — Ensure students participating in medications should be held, have resulted Healthcare students can and do play a role the medication-use process are in dose omissions and the administra- in catching and uncovering medication appropriately supervised by faculty tion of extra doses. Communication errors. A retrospective study confirmed or preceptors during their clinical Page 22 Pennsylvania Patient Safety Advisory Vol. 13, No. 1—March 2016 ©2016 Pennsylvania Patient Safety Authority rotations.3,4 This includes having the — Incorporate medication safety error-prone conditions with students instructor or preceptor present at the throughout student curriculums.4,12 and preceptors.4,15 bedside during the time of medica- Employ both didactic and experien- tion administration. tial methodologies. CONCLUSION — Verbally confirm actions of medica- — Design healthcare professional To develop their clinical reasoning tion administration in presence of education programs to include abilities, students engage in experiential instructor or preceptor. multidisciplinary clinical simulation training in U.S. hospitals.4 Students not — Ensure that staff complete documen- training before clinical rotations to only learn how to care for patients and tation in a timely fashion if students develop the ability to work in teams operate as a member of a team, but often are involved in patient care. Provide and reduce medication errors.3,4,18 enrich the patient’s experience during students with the ability to review — Establish an orientation and train- hospitalization.15 Any participation in the and document medication-adminis- ing process for students and faculty. medication-use process places students in tration information in the paper or Include a review of relevant elec- a position to be involved in medication electronic MAR.15 tronic systems (e.g., EHR, barcode errors, as well as a position from which — Share the facility’s list of high-alert scanning, automated dispensing to identify potential or actual errors.5 drugs and associated error-reduction cabinets). Also include review of Professional organizations, healthcare strategies with instructors and stu- the location (e.g., patient care area) facilities, and professional schools should dents to ensure the same level of where they will be involved in the work collaboratively to address factors attention to safe systems and prac- medication-use process.4 that may contribute to errors involving tices occurs when students handle — Establish a non-punitive reporting students (and instructors) while maximiz- these drugs.15 culture to encourage discussion of ing the students’ ability to intercept and prevent errors. NOTES 1. Ofosu R, Jarrett P. Reducing nurse medi- 7. American Association of Colleges of Phar- 13. Vaismopradi M, Jordan S, Turunen H, et cine administration errors. Nurs Times macy. Academic pharmacy’s vital statistics al. Nursing students’ perspectives of the 2015 May 13-19;111(20):12-4. [online]. 2015 Nov 16 [cited 2015 Nov cause of medication errors. Nurse Educ 2. American Association of Colleges of 25]. http://www.aacp.org/about/pages/ Today 2014 Mar;34(3):434-40. Nursing. The essentials of baccalaure- vitalstats.aspx 14. American Association of Colleges of ate education for professional nursing 8. Association of American Medical Col- Nursing. Expectations for practice practice [online]. 2008 Oct 20 [cited 2015 leges. Member directory [online]. 2015 experiences in the RN to baccalaureate Nov 25]. http://www.aacn.nche.edu/ [cited 2015 Nov 25]. https://members. curriculum [online]. 2012 Oct [cited 2015 education-resources/BaccEssentials08.pdf aamc.org/eweb/DynamicPage.aspx?site=A Nov 25]. http://www.aacn.nche.edu/ 3. Reid-Searl K, Moxham L, Happell B. AMC&webcode=AAMCOrgSearchResult aacn-publications/white-papers/RN-BSN- Enhancing patient safety: the impor- &orgtype=Medical%20School White-Paper.pdf tance of direct supervision for avoiding 9. Commission on Collegiate Nursing 15. Institute for Safe Medication Practices. medication errors and near misses by Education. Standards for accreditation Error-prone conditions that lead to stu- undergraduate nursing students. Int J Nurs of baccalaureate and graduate degree dent nurse-related errors. ISMP Med Saf Pract 2010 Jun;16(3):225-32. nursing programs [online]. 2013 [cited Alert Acute Care 2007 Oct 18;12(21):1-2. 4. Wolf ZR, Hicks R, Serembus JF. Char- 2015 Nov 25]. http://www.aacn.nche. Also available at: http://www.ismp.org/ acteristics of medication errors made by edu/ccne-accreditation/Standards- Newsletters/acutecare/articles/ students during the administration phase: Amended-2013.pdf 20071018.asp a descriptive study. J Prof Nurs 2006 Jan- 10. National Coordinating Council for Medi- 16. Valdez LP, de Guzman A, Escolar-Chua Feb;22(1):39-51. cation Error Reporting and Prevention. R. A structural equation modeling of 5. Mathys M, Neyland-Turner E, Hamouie NCC MERP index for categorizing medi- the factors affecting student nurses’ K, et al. Effect of pharmacy students as cation errors [online]. 2001 Feb [cited medication errors. Nurse Educ Today 2013 primary members on inpatient interdisci- 2015 Nov 25]. http://www.nccmerp.org/ Mar;33(3):222-8. plinary mental health teams. Am J Health medErrorCatIndex.html 17. Page K, McKinney AA. Addressing medi- Syst Pharm 2015 Apr 15;72(8):663-7. 11. Institute for Safe Medication Practices. cation errors - the role of undergraduate 6. Pennsylvania State Board of Nursing. ISMP’s list of high-alert medications nurse education. Nurse Educ Today 2007 Approved nursing programs [online]. [online]. 2014 [cited 2015 Nov Apr;27(3):219-24. 2015 Oct 5 [cited 2015 Nov 25]. http:// 25]. http://www.ismp.org/Tools/ 18. Sears K, Goldsworthy S, Goodman W. www.dos.pa.gov/ProfessionalLicensing/ institutionalhighAlert.asp The relationship between simulation in BoardsCommissions/Nursing/ 12. Harding L, Petrick T. Nursing student nursing education and medication safety. Documents/Applications%20and%20 medication errors: a retrospective review. J Nurs Educ 2010 Jan;49(1):52-5. Forms/RN%20Programs.pdf J Nurs Educ 2008 Jan;47(1):43-7. Vol. 13, No. 1—March 2016 Pennsylvania Patient Safety Advisory Page 23 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 1—March 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org. An Independent Agency of the Commonwealth of Pennsylvania ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 50 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.