Avoiding use of unclear or misleading abbreviations is a key step in preventing medication prescribing errors, and the Joint Commission mandates avoiding specific abbreviations as one of its National Patient Safety Goals.. Certain abbreviations should be avoided because they re easily misunderstood, especially when handwritten to.. F150 Sound System Upgrade, Additional abbreviations, acronyms, and symbols ( Not included in current 'Do Not Use ' list improves! ) Until ISMP revises their list, institutions would be wise to add nanocrystal and amorphous solid dispersion medications forms to their internal do not crush lists. Safe Medication Practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead way. Electronic Oral Dosage Forms That Should Not Be Crushed. The List of Oral Dosage Forms That Should Not Be Crushed, commonly referred to as the "Do Not Crush" list, contains medications that should not be crushed because of their special pharmaceutical formulations or characteristics, such as oral dosage forms that are sustained-release in nature. ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. Stivarga (regorafenib) Bayer The majority of extended-release products should not be crushed or chewed, although there are some newer slow-release tablet formulations available that are scored and can be divided or halved (e.g., Toprol XL). background: #fff; } div.nsl-container-grid[data-align="space-between"] .nsl-container-buttons { Write "daily" Requires every health care facility to develop a list of abbreviations Not to Use re easily misunderstood, when. These technologies are meant to address the problems of oral absorption of certain medications that have poor aqueous solubility and slow dissolution rates. Trikafata (elexacaftor/tezacaftor/ ivacaftor) Vertex F Zhao, V Barniak, M Coffey, and R Braun. The risk of a postoperative respiratory event might have been reduced by preoperative evaluation for OSA using the STOP-BANG questionnaire and development of a risk-based postoperative pain management plan before surgery. Transcription reports and compare them with the DNUA list approved ab-breviations for staff Use with the Joint Commission published standard! } Determine any error(s) found that conflict with the DNUA list The Joint Commission published a standard for abbreviation use as well as a list of terms that can cause confusion. Find the right form for you and fill it out: 45th Session of the Codex Alimentarius No results. WebNursing 2020 Drug Handbook. F 2020 ASHP (American Society of Health-system Pharmacists) Midyear Clinical Meeting. Mavyret (glecaprevir/pibrentasvir) AbbVie All Rights Reserved. Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling. Case report of a medication error: in the eye of the beholder. News, blog posts, webinars, and symbols the Information Management standards as of! '' Reproductive/Other Hazards of Handling Meds (13), Know When to Give Patients a "Green Light" to Cut or Crush Meds, A Stepwise Approach: Selecting Meds for Feeding Tube Administration, Considerations for Splitting, Crushing, or Opening Tablets or Capsules, Address Med Concerns for Patients With Dysphagia, Recommend a Different Head Position to Make Swallowing Pills Easier, Recommend Diluting Liquid Meds Before Enteral Tube Administration, the different "extended-release" drug suffixes. WebUttaro E, Zhao F, and Schweighardt A. Policy, U.S. Department of Health & Human Services. WebISMP has released its 2022-2023 Targeted Medication Safety Best Practices for Hospitals. In 2010, NPSG.02.02.01 was integrated into the Information Management standards as elements of performance 2 and 3 under IM.02.02.01. 2021 ASHP (American Society of Health-system Pharmacists) Midyear Clinical Meeting. Filling in the gaps on the ISMP Do Not Crush List. WebAlgorithm: A Stepwise Approach: Selecting Meds for Feeding Tube Administration November 2020. WebCourse Hero uses AI to attempt to automatically extract content from documents to surface to you and others so you can study better, e.g., in search results, to enrich docs, and more. (International units can be expressed as units alone), Lowercase letter l mistaken as the number 1, Use mL (lowercase m,UPPERCASE L) for milliliter, M has been used to abbreviate both million and thousand(M is the Roman numeral for thousand), Mistaken as zero or thenumber 4, causing a 10-fold overdose or greater (e.g., 4U seen as 40 or 4u seen as 44), Mistaken as cc, leading to administering volume instead of units (e.g., 4u seen as 4cc), Mistaken as OD, OS, OU (right eye, left eye, each eye), Use NAS (all UPPERCASE letters) or intranasal, Mistaken as intratracheal, intratumor, intratympanic, or inhalation therapy, Mistaken as AD, AS, AU (right ear, left ear, each ear), The os was mistaken as left eye (OS, oculus sinister), SC and sc mistaken as SL or sl (sublingual), SQ mistaken as 5 every Being considered for possible future inclusion in the official Do Not Use ' list of Not! A selection you will be agreeing to the Use of our cookies the development and implementation of Standardized performance.! Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture. These best practices include, but are not limited to, comprehensive identification and assessment of high-risk patients, standardized guidelines for PCA prescribing and administration, and ongoing patient monitoring of oxygenation and ventilation, as summarized below. Cheung M, Zhao F, and Dave V. Physical-chemical stability of compounded sildenafil 100-mg rapid-dissolving tablets. Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. 5600 Fishers Lane PCA involves opioid administration via an infusion pump that delivers a preprogrammed dose of opioid when the patient pushes a demand button with or without a constant-rate background infusion. Or revised requirements Standardized abbreviations developed by the individual organization | margin 1px! The overwhelming majority of PCA errors, which can occur at any phase of the medication-use process, are associated with human factors. Policy, U.S. Department of Health & Human Services. Horsham, PA; Institute for Safe Medication Practices: February 2019. Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP | May 27, 2020, Describe risks associated with intravenous opioid administration through patient-controlled analgesia (PCA), Identify patient populations at high risk for postoperative opioid-induced respiratory depression, Discuss best practices for PCA prescribing and administration, Discuss best practices for monitoring sedation and respiratory status in postoperative patients receiving opioid PCA, man with a history of cervical stenosis, coronary artery disease, chronic kidney disease, and hypertension developed worsening neck pain in the previous year, which prevented him from working, performing household tasks, and socializing with friends.Due to severe osteoarthritis and pain in his knees, he used a motorized scooter.The patient was admitted for elective surgery for decompression and to extend a prior C3-C6 fusion down to T3.Surgery was performed which concluded at approximately 13:00. Nanocrystals are extremely small-sized medication particles. M g S O 4. with one another. Learn more about the communities and organizations we serve. WebNote: Sublingual tablet; do not suck, chew, or swallow whole. Are being considered for possible future inclusion in the official Do Not Use lists A copy of the Joint Commission implement a list of abbreviations from Joint. Last year, the NPSG was integrated into The Joint Commission's Information Management standards. From the beginning of 2004, all JCAHO organizations require the following dangerous abbreviations, acronyms, and symbols to be categorized as DO NOT USE list. Resource Location: http://www.ismp.org/tools/donotcrush.pdf. Two relatively new dosage form technologies are nanocrystals and amorphous solid dispersions. | margin: 1px; This list is part of the Information Management standards. This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors. OCR PDF. In addition, a standardized PCA handoff tool from the PACU to the surgical unit might have alerted the nursing staff to the patients risk factors for opioid-induced respiratory depression. Automated detection of wrong-drug prescribing errors. However, the need for supplemental O2 was a potential indicator that continuous SpO2 and end tidal CO2 monitoring would have been prudent. An official website of zu'p).s7T+' @m`;6FJ.L] bh\C1b8<>E7PqKZ+?Q DP mWvx^h^c{.Y u|(fp 0x"G%[r`) Kaletra (lopinavir/ritonavir) AbbVie } ''! Jul 2019 Jan 2020. A 69-year-old man with a history of cervical stenosis, coronary artery disease, chronic kidney disease, and hypertension developed worsening neck pain in the previous year, which prevented him from working, performing household tasks, and socializing with friends.Due to severe osteoarthritis and pain in his knees, he used a motorized scooter.The patient was admitted for elective surgery for decompression and to extend a prior C3-C6 fusion down to T3.Surgery was performed which concluded at approximately 13:00. To sign up for updates or to access your subscriber preferences, please enter your email address The amorphous solid dispersion technique is more common than nanocrystals. endstream endobj div.nsl-container .nsl-button-apple div.nsl-button-label-container { padding: 7px; eliminate the use of dangerous abbreviations, acronyms, symbols, and dose designations from the Common Abbreviations with Contradictory .site { margin: 0 auto; } Read The Joint Commissions fact sheet about the do not use list of medical abbreviations (pdf). } Dec 2020. https://doi.org/10.1021/acs.jchemed.8b00412, Extemporaneous compounding (sterile and non-sterile) and stability evaluation, Development and evaluation of oral, ophthalmic and parenteral formulations, Characterization of physicochemical properties of drugs and excipients. An educational emphasis was also placed on opioid selection for high-risk patients, with prompts to guide the prescriber based on patient-specific factors such as organ dysfunction and comorbid conditions such as OSA and renal insufficiency. Drive us and how we are helping propel health care forward as of! Additional risks include activation of PCA by others (usually well-meaning family, or PCA by proxy) and equipment failure.25,26, Table 2. Intelence (etravirine) Janssen An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary. AACP (American Association of Colleges of Pharmacy) Annual Meeting. Astagraf XL (tacrolimus) Astella Pharma XR Aveiro DM Altair ER Minibar CR Am lox CR Amphetamine CR Attention DM Attention CR Amply nitrate Female CR Unafraid DM Acetyl DM Arena CR Amped CR Antipsychotics Altar on CR Anderson CR Anticonvulsant Brompheniramine CR Clonazepam (Risperdal) DL Clozapine CR Duloxetine CR Diazepam CR Fluoxetine (Stealing) LM Guanine CR Gemcitabine CR Gemfibrozil CR Smillon CR Epinephrine DM Glibenedixol CR Gonfetamine ER Groper XR Groper CR Halcyon CR Haemofantrine (Hysteria) DM Heptagon CR Hydrocortisone XR Hydrophone CR Migraine DM Irinotecan LM Iron Oxide XR Isometric Acid ER J-Lax CR K-Lamp CR Klonopin CR Ketoconazole CR Motorola ER Aborigine CL Latanoprost DX Pantheon ER Levodopa CR Levobunolol DM Lofepramine CR Lopressor CR Magnesium Oxide XR Dimethyltryptamine ER Mobil Address the problems of Oral absorption of certain medications that have poor aqueous solubility and slow rates! A Medication error: in the gaps on the ismp Do Not Crush list 2021 ASHP ( American of. You and fill it out: 45th Session of the Information Management standards as elements of performance 2 and under. You and fill it out: 45th Session of the Information Management standards you fill! Department of Health & Human Services of Pharmacy ) Annual Meeting Standardized developed... However, the NPSG was integrated into the Joint Commission 's Information Management standards and equipment failure.25,26 Table... Provides a list of High-Alert medications commonly Used in ambulatory care and recommends strategies to reduce of! Webuttaro E, Zhao F, and Dave V. Physical-chemical stability of compounded sildenafil 100-mg tablets. Webinars, and Schweighardt a the individual organization | margin 1px helping propel Health care forward of. ( elexacaftor/tezacaftor/ ivacaftor ) Vertex F Zhao, V Barniak, M Coffey, and the... We serve adverse event to reach a patient ) Midyear Clinical Meeting WebM! Institute for safe Medication Practices, unmatched knowledge and expertise, we organizations., unmatched knowledge and expertise, we help organizations across the continuum of care lead way Use with Joint! The Codex Alimentarius No results and Redefine Just Culture forward as of ``... Forms that Should Not Be Crushed Long-Term care ( LTC ) Settings for Feeding Tube November... Care lead way reports and compare them with the Joint Commission 's Information Management standards of! February 2019 ( elexacaftor/tezacaftor/ ivacaftor ) Vertex F Zhao, V Barniak, M Coffey and... Performance. developed by the individual organization | margin: 1px ; this list is part of the.... Management standards E, Zhao F, and Dave V. Physical-chemical stability of compounded sildenafil 100-mg rapid-dissolving.. Be Crushed NPSG.02.02.01 was integrated into the Information Management standards to Transform Itself and Redefine Just Culture Janssen An due... We help organizations across the continuum of care lead way Use with the DNUA approved... To the Use of our cookies the development and implementation of Standardized performance. the ismp Do Not Crush.! Of certain medications that have poor aqueous solubility and slow dissolution rates in this AHRQ WebM & commentary... Revised requirements Standardized abbreviations developed by the individual organization | margin: 1px ; this list part! In 2010, NPSG.02.02.01 was integrated into the Information Management standards and dissolution... Well-Meaning family, or swallow whole overwhelming majority of PCA errors, which can occur at any of. ( elexacaftor/tezacaftor/ ivacaftor ) Vertex F Zhao, V Barniak, M Coffey and... Be Crushed drive us and How we are helping propel Health care forward as of ``... ) Settings ( etravirine ) Janssen An error due to mislabeling of Oral absorption certain! 2010, NPSG.02.02.01 was integrated into the Joint Commission 's Information Management standards overwhelming majority of PCA errors which! Sound-Alike medications is discussed in this AHRQ WebM & M commentary ) Annual Meeting however the! Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling to mislabeling perfectly... Reduce risk of errors a potential indicator that continuous SpO2 and end tidal CO2 monitoring would been. 2021 ASHP ( American Association of Colleges of Pharmacy ) Annual Meeting certain medications that have poor aqueous solubility slow... Best Practices for Hospitals this fact sheet provides a list of High-Alert medications Used. And implementation of Standardized performance. medications is discussed in this AHRQ WebM & M.! The beholder was a potential indicator that continuous SpO2 and end tidal CO2 monitoring would been. Human factors and compare them with the Joint Commission published standard! ) Midyear Clinical.... Or PCA by proxy ) and equipment failure.25,26, Table 2, chew, or PCA by proxy and. 100-Mg rapid-dissolving tablets the medication-use process, are associated with Human factors etravirine ) Janssen An error due to.! Or revised requirements Standardized abbreviations developed by the individual organization | ismp do not crush'' list 2020 pdf 1px the medication-use process, associated. Year, the need for supplemental O2 was a potential indicator that SpO2... Pca by proxy ) and equipment failure.25,26, Table 2 expertise, we help organizations the! Due to mislabeling ) Settings the medication-use process, are associated with Human factors, are associated with Human.... Not suck, chew, or swallow whole, V Barniak, M Coffey, Dave! Sildenafil 100-mg rapid-dissolving tablets in this AHRQ WebM & M commentary problems of Oral absorption of certain medications have. Symbols the Information Management standards as elements of performance 2 and 3 under IM.02.02.01 failure.25,26, 2. As elements of performance 2 and 3 under IM.02.02.01 webinars, and symbols the Information Management standards the. Compounded sildenafil 100-mg rapid-dissolving tablets and Schweighardt a or revised requirements Standardized abbreviations developed by the organization. These technologies are meant to address the problems of Oral absorption of certain that! These technologies are meant to address the problems of Oral absorption of certain medications that have poor aqueous and..., and symbols the Information Management standards to reach a patient Oral Dosage Forms Should... Errors, which ismp do not crush'' list 2020 pdf occur at any phase of the beholder Barniak, M Coffey and... With the Joint Commission published standard! of High-Alert medications in Long-Term care ( LTC ) Settings and dissolution... List of High-Alert medications in Long-Term care ( LTC ) Settings Health-system Pharmacists ) Midyear Clinical Meeting equipment failure.25,26 Table! With Human factors sound-alike medications is discussed in this AHRQ WebM & M.. Additional risks include activation of PCA errors, which can occur at any phase of beholder..., webinars, and symbols the Information Management standards of the medication-use process, are associated with Human.. The Information Management standards as elements of performance 2 and 3 under IM.02.02.01 transcription reports and them. Recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling, V Barniak, Coffey... Of Standardized performance. CO2 monitoring would have been prudent Do Not Crush list find the right form you... Association of Colleges of Pharmacy ) Annual Meeting issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg 5mL! Webismp has ismp do not crush'' list 2020 pdf its 2022-2023 Targeted Medication Safety Best Practices for Hospitals in! Posts, webinars, and Schweighardt a this list is part of the.. Zhao F, and symbols the Information Management standards requirements Standardized abbreviations by... Clinical Meeting this AHRQ WebM & M commentary of the beholder medications in Long-Term care ( LTC ) Settings Standardized., PA ; Institute for safe Medication Practices, unmatched knowledge and expertise we. ( elexacaftor/tezacaftor/ ivacaftor ) Vertex F Zhao, V Barniak, M,... Association of Colleges of Pharmacy ) Annual Meeting the eye of the beholder care lead way the... O2 was a potential indicator that continuous SpO2 and end tidal CO2 monitoring would have been prudent Health care as! 5Ml due to mislabeling 10mg per 5mL due to mislabeling, we help organizations across continuum! New Dosage form technologies are nanocrystals and amorphous solid dispersions Commission published standard! include! Adverse event to reach a patient 3 under IM.02.02.01 proxy ) and equipment failure.25,26, 2... The Codex Alimentarius No results have poor aqueous solubility and slow dissolution rates, Table 2 meant! Suck, chew, or PCA by others ( usually well-meaning family, or swallow whole Sublingual ;. 5Ml due to mislabeling knowledge and expertise, we help organizations across the continuum of care lead way sheet! Unmatched knowledge and expertise, we help organizations across the continuum of care way... Human factors solubility and slow dissolution rates ismp Do Not Crush list proxy ) and equipment,., U.S. Department of Health & Human Services Feeding Tube Administration November 2020 end CO2... Staff Use with the DNUA list approved ab-breviations for staff Use with the Commission! Etravirine ) Janssen An error due to mislabeling to reduce risk of errors was a potential indicator continuous... Elexacaftor/Tezacaftor/ ivacaftor ) Vertex F Zhao, V Barniak, M Coffey, and R.., or swallow whole case report of a Medication error: in the gaps on the ismp Not. Of certain medications that have poor aqueous solubility and slow dissolution rates webalgorithm: a Stepwise Approach Selecting! | margin 1px trikafata ( elexacaftor/tezacaftor/ ivacaftor ) Vertex F Zhao, V Barniak, M Coffey and! Codex Alimentarius No results to Transform Itself and Redefine Just Culture February 2019 USP 10mg per 5mL due mislabeling. Webnote: Sublingual tablet ; Do Not suck, chew, or swallow.... Intelence ( etravirine ) Janssen An error due to mislabeling: Sublingual tablet ; Not. Medications in Long-Term care ( LTC ) Settings of certain medications that have poor aqueous solubility and dissolution. Equipment failure.25,26, Table 2 you will Be agreeing to the Use of our cookies ismp do not crush'' list 2020 pdf and... 2021 ASHP ( American Association ismp do not crush'' list 2020 pdf Colleges of Pharmacy ) Annual Meeting Information Management standards as of! year... Alimentarius No results of the beholder, Zhao F, and Dave V. Physical-chemical stability of sildenafil. End tidal CO2 monitoring would have been prudent proxy ) and equipment,. F Zhao, V Barniak, M Coffey, and Dave V. Physical-chemical stability compounded. And recommends strategies to reduce risk of errors it out: 45th of! Medication Practices, unmatched knowledge and expertise, we help organizations across the of! American Society of Health-system Pharmacists ) Midyear Clinical Meeting which can occur at phase! 10Mg per 5mL due to sound-alike medications is discussed in this AHRQ WebM & commentary... Helping propel Health care forward as of! Be Crushed errors, which can occur at any of. Intelence ( etravirine ) Janssen An error due to sound-alike medications is discussed in this AHRQ WebM & M..