Multifactorial Causes of Tacrolimus Errors: Confusion With Strength/Formulation, Look-Alike Names, Preparation Errors, and More Ensuring Safety of Recipes for Drug Compounding Please, no more teaspoon dosing.

A recent string of errors associated with tacrolimus, an immunosuppressant used primarily to prevent rejection in transplant recipients, prompted ISMP to review the literature and analyze related events reported to the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) and the ISMP National Medication Errors Reporting Program (MERP). We found that tacrolimus has been involved in many reported errors during the past decade that have been caused by a wide variety of factors, the most common of which are described below.

ISMP Medication Error Report Analysis.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

ISMP Medication Error Report Analysis: Potential Issues with New Basal Insulin/GLP-1 Fixed Combinations Hydroxyzine-Hydroxyurea Mix-up Concomitant Use of Entresto and ACE Inhibitors Can Lead to Serious Outcomes More Outpatient Oral Cancer Drugs Should Be in Blister Packs.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

ISMP Medication Error Report Analysis: Betaine Anhydrous Versus Betaine Hydrochloride Look-Alike Generic Names Don't Give Zurampic Without Allopurinol Lantus Overdose Tied to Confusing Vial Label More on Lipid Rescue.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

ISMP Medication Error Report Analysis.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

ISMP Medication Error Report Analysis: Understanding Human Over-reliance on Technology It's Exelan, Not Exelon Crash Cart Drug Mix-up Risk with Entering a "Test Order".

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

ISMP Medication Error Report Analysis: Aggrastat-Argatroban Mix-ups Don't Expect Radiofrequency Identification Stock Systems To Be Perfect Paralyzed by Mistakes: Reassess the Safety of Neuromuscular Blockers in Your Facility.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

ISMP Medication Error Report Analysis: Reporting and Second-Order Problem Solving Can Turn Short-Term Fixes Into Long-Term Remedies Fifty Hospital Employees Given Insulin Instead of Influenza Vaccine Reminder: Eliminating Ratio Expressions Strength Confusion.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural-safeguards, they can be avoided.

Alteplase and Tenecteplase Confusion; Lack of E-Prescribing Interoperability Leads to Double Dosing; Accidental Overdoses Involving Fluorouracil Infusions.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Prescribing Errors with Levetiracetam Oral Solution; Communicate Insulin Dose and Concentration on Separate Lines; Risperidone and Ropinirole Mix-ups; IV Line Disinfection Caps Can Become Foreign Bodies.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

FDA Advise-ERR: Mefloquine-Not the Same as Malarone; Zoster Vaccine Is Not for the Immunosuppressed; TXA Mistaken as Tenecteplase; Guidelines for Adult IV Push Medications.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Partially Filled Vials and Syringes in Sharps Containers Are a Key Source of Drugs for Diversion: ISMP Targeted Medication Safety Best Practice #9 Are Patients Who Are Allergic to Antibiotics at Risk for Reactions to Vaccine Ingredients?

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Selected Medication Safety Risks to Manage in 2016-Part II; Methylergonovine Errors in Obstetrics.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Selected Medication Safety Risks to Manage in 2016-Part I Intravenous Fat Emulsion Needs a Filter.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Pen Device for U-500 Insulin; Tamper-Resistant Seals; Dispelling Myths About ISMP.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Key Vulnerabilities in the Surgical Environment: Container Mix-Ups and Syringe Swaps Do Not Confuse Idarucizumab with Idarubicin.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Oxycodone IV?; Eliminate Teaspoonfuls; Avoid Vitamin D Products Dosed and Measured in Drops.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Methylene Blue is a Monoamine Oxidase Inhibitor; Severe Harm and Death Associated with Low-Dose Methotrexate; Potentially Dangerous Mix-up between Cancer Drugs.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Avoid Using the Error-Prone Abbreviation "TPA"; Unexpected Painful Breath; Mix-ups among "V" Drugs; : Name Change Needed.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Patient-Controlled Analgesia Basal Infusion Overdose; Life-threatening Errors with Flecainide Suspension in Children; Medical Product Error-Prevention Efforts Need to Be Shared and Harmonized Internationally.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Delayed Administration and Contraindicated Drugs Place Hospitalized Parkinson's Disease Patients at Risk; Doxorubicin Liposomal Mix-up; Avoid Mix-ups Between Hydroxyprogesterone and Medroxyprogesterone.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.

Propylene Glycol Toxicity with Stoss Therapy; State Drug Tracking Database Helps Prevent an Error; Where Did That Medication Come From?; Expiration Date Difficult to Read.

These medication errors have occurred in health care facilities at least once. They will happen again-perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided.