Abstract
The Institute for Safe Medication Practice’s (ISMP) annual Top 10 Medication Errors and Hazards list may or may not include the most frequently reported errors or the errors that cause the most serious harm to patients. Instead, ISMP’s list focuses primarily on the most stubborn errors—the ones that occur year after year, even though certain practice or system changes are known to mitigate or avoid them. But new and emerging threats also earned spots in the 2020 edition, and their origin is unsurprising.
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