ismp do not crush'' list 2021

91 0 obj <> endobj Bar-code technology for medication administration: medication errors and nurse satisfaction. Bidex A (combination) Tablet Slow-release MeSH Institute for Safe MedicationPractices Kadian (morphine) Capsule Slow-release (a) (Note: do not give via NG tubes) Jentadueto XR (combination) Tablet Slow-release Learn more information here. bioavailability of drug (b) Crixivan (indinavir) Capsule Taste (Note: capsule may be opened and mixed with Easprin (aspirin) Tablet Enteric-coated Purchase Wall Chart from Thomas Land Publishers, Wall Chart - Compatibility of Critical Care Admixtures, Wall Chart - Medications That Should Not Be Transported Via Pneumatic Tube Systems, Medication Safety Officers Society (MSOS). Urocit-K (potassium citrate) Tablet Wax-coated; prevents upper GI release Proscar (finasteride) Tablet Note: women who are, or may become, pregnant, Would you like email updates of new search results? 2021 Feb 19;78(5):389-394. doi: 10.1093/ajhp/zxaa412. Federal government websites often end in .gov or .mil. 2021 Feb 19;78 (5):389-394. doi: 10.1093/ajhp/zxaa412. Erivedge (vismodegib) Capsule Note: package insert indicates potential teratogenic 2023 Institute for Safe Medication Practices. (i) Skin contact may enhance tumor production; avoid direct contact. Bethesda, MD 20894, Web Policies Authors Elizabeth Uttaro 1 , Madhu Pudipeddi 2 , Anne Schweighardt 1 3 , Fang Zhao 3 Affiliations precautions Additionally, you may type in free text in the search box and click the SUBMIT button below. Envarsus XR (tacrolimus) Tablet Slow-release Verma MM, Kumar MT, Balasubramaniam J, Pandit JK. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education2015. contact; health care workers should take appropriate Quick Guide to Standards of Care for Chronic Disease Screening: Diabetes Self-Management Training (DSMT) provided by Diabetes Care and Education Specialist (CDCES, Quick Guide to Standards of Care for Chronic Disease Screening: Connect Patients Eligible for Cardiac Rehabilitation to Life-Saving Services, Considerations for Referring Patients to RDN for Medical Nutrition Therapy (MNT) Services for Diabetes and Chronic Kidney Disease Care, Quick Guide to Standards of Care for Chronic Disease Screening: Blood Pressure Screening Recommendations for Hypertension (HTN), Chronic Kidney Disease Awareness and Prevention Program. Drug name pairs or larger groupings that look similar utilize bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names. Hzr``bdx c`@ b sharing sensitive information, make sure youre on a federal You may purchase a wall chart version of this list at: Drug Product Active Ingredient(s) Dosage Form(s) Reasons/Comments NurseyPoo7 275 Posts Specializes in Acute Care. potentially fatal dose of oxy CODONE ), Tasigna (nilotinib) Capsule Note: disruption of capsule may yield high blood levels Its creator received a 2007 ISMP Cheers award. Mitchell JF; Institute for Safe Medications Practices; ISMP. March 12, 2021. TheList 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. The 2004 list was updated in 2010, 2012 and 2014. When the Indications for Drug Administration Blur, Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. Policies, HHS Digital Search All AHRQ Bidhist-D (combination) Tablet Slow-release Us, Annual Perspective: Topics in Medication Safety. 2021 Jun 15;13(6):889. doi: 10.3390/pharmaceutics13060889. Horizant (gabapentin) Tablet Slow-release Search All AHRQ potentially fatal dose of HYDRO codone), Imbruvica (ibrutinib) Capsule Note: not scored; no studies available from company, Imdur (isosorbide) Tablet Slow-release (h) mucosa; choking could occur Nucynta ER (tapentadole) Tablet Slow-release (Note: crushing, chewing, or dissolving While every effort has been made to ensure the accurcay and completeness suspension, Jalyn (combination) Capsule Mucous membrane irritant (Note: women who are, or Effervescent Potassium ------ Tablet Effervescent tablet (f) Utilization of pharmacy technicians to increase the accuracy of patient medication histories obtained in the emergency department. Droxia (hydroxyurea) Capsule Note: exposure to the powder may cause serious skin Lescol XL (fluvastatin) Tablet Slow-release Isordil Sublingual (isosorbide) Tablet Sublingual form (g) If the medication is altered or destroyed in any way, the medication will be released too fast and cause an adverse effect. American Society of Health-System Pharmacists 2020. Plymouth Meeting, PA 19462. ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. International Journal of Pharmaceutical Compounding. Medication administration in anesthesia: time for a paradigm shift. Plymouth Meeting, PA 19462. Touro LA-LD (combination) Tablet Slow-release (h) capsules require rigorous precautions to avoid Ranexa (ranolazine) Tablet Slow-release [2] Activities [ edit] ISMP encourages that organizations maintain, update, and periodically review a list of oral dosage forms that may require alteration through evaluation of package inserts, drug manufacturer inquiries, tertiary drug information resources, and primary literature. Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. Voltaren XR (diclofenac) Tablet Slow-release government site. The https:// ensures that you are connecting to the Toprol XL (metoprolol) Tablet Slow-release (h) potentially fatal overdose of oxy CODONE), Pancreaze (pancrelipase) Capsule Enteric-coated (a) 4849 0 obj <>stream Oleptro (tra ZOD one) Tablet Slow-release (h) Dilt-CD (diltiazem) Capsule Slow-release Renagel (sevelamer) Tablet Note: tablets expand in liquid if broken or crushed, Sudafed 12 hour (combination) Capsule Slow-release (b) (e) The taste of this product form would likely be unacceptable to the patient; administration via nasogastric tube should be acceptable. Hydrea (hydroxyurea) Capsule Note: exposure to the powder may cause serious skin Symax Duotab (hyoscyamine) Tablet Slow-release Xarelto (rivaroxaban) Tablet Note: crushed tablet must be given within 4 hours. Aggrenox (combination) Capsule Slow-release This site needs JavaScript to work properly. - Do not crush (risk of sensitization, and taste is unacceptable for oral administration) cinacalcet Sensipar Tablet Note: tablets are not scored and cutting may cause variable dosage accuracy cloNIDine Kapvay Tablet Slow-release - Do not crush sustained-release product - Immediate-release tablet may disperse 2022 May 18. absorption Sites, Contact Two summary tables along with the conditional recommendations are provided for pharmacists and other healthcare providers to aid in clinical decision making. causing enhanced toxicity Effer-K (potassium bicarbonate) Tablet Effervescent tablet (f) Top 10 Medication Errors and Hazards that appeared in the ISMP Medication Safety Alert! To search resources by focus area, simply click on the box to the left of the focus area below. Diltia XT (diltiazem) Capsule Slow-release Votrient (pazopanib) Tablet Note: crushing significantly increases the AUC and Temodar (temozolomide) Capsule Slow-release (Note: accidentally opened or damaged Our error reporting program, education, and advocacy have helped protect millions of patients. Epub 2017 Nov 10. This chart defines the stability and compatibility of medications that are routinely present in critical care, and intensive care settings. NP Safe Prescribing Of Controlled Substances While Avoiding Drug Diversion. water only and dispense via dosing syringe of NG tube, Prevacid Suspension (lansoprazole) Suspension Slow-release (Note: contains enteric-coated granules; 5600 Fishers Lane Durlaza (aspirin) Capsule Slow-release ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing-2019. 8600 Rockville Pike Table 1 provides a summary list of drug products based on nanocrystal or amorphous solid dispersion technologies that were approved by FDA as of December 31, 2019. Uttaro E, Pudipeddi M, Schweighardt A, Zhao F. Am J Health Syst Pharm. Iressa (gefitinib) Tablet Note: tablet may be dissolved in 4-8 ounces of water, Isoptin SR (verapamil) Tablet Slow-release (h) Afinitor (everolimus) Tablet Mucous membrane irritant potentially fatal overdose of drug) In: StatPearls [Internet]. Viramune XR (nevirapine) Tablet Slow-release (b) Learn more information here. To sign up for updates or to access your subscriber preferences, please enter your email address ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. Clin Pharmacol Drug Dev. VESIcare (solifenacin) Tablet Enteric-coated 1. Dulcolax (bisacodyl) Capsule; Tablet Enteric-coated (c); Liquid-filled Isosorbide Dinitrate Sublingual (isosorbide) Tablet Sublingual form (g) Document number: 010-03-09-004 Review date: April 2021 Developed and maintained by Bernadette Rehman, Clinical Pharmacist, Residential Aged Care, Waitemata District Health Board, New Zealand and . Depakote ER (divalproex) Tablet Slow-release Exjade deferasirox Tablet Note: do not give as tablet; tablets are meant to be given as a liquid; see company insert. Ampyra (dalfampridine) Tablet Slow-release (Note: formerly fampridine-SR) Sites, Contact Allegra-D (combination) Tablet Slow-release Procardia XL ( NIFE dipine) Tablet Slow-release Oramorph SR (morphine) Tablet Slow-release (b) Policy, U.S. Department of Health & Human Services. than half) ISMP Do Not Crush List November 1, 2018. Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States. 114 0 obj <>/Encrypt 92 0 R/Filter/FlateDecode/ID[<9C316512FA01DB64926B07496F4C98EF><2051BE4FD64FB74C8C9DFE3DFF6A8BC1>]/Index[91 40]/Info 90 0 R/Length 105/Prev 229382/Root 93 0 R/Size 131/Type/XRef/W[1 2 1]>>stream Aquatab D (combination) Tablet Slow-release (h), Aricept 23 mg (donepezil) Tablet Note: crushing the 23 mg tablet may significantly To ensure that certain medications are used safely, this updated list includes oral medications that should not be crushed and specifies why. Extendryl (all) combination Capsule Extendedrelease (b) Feenamint bisacodyl Tablet Entericcoated (c) Feldene piroxicam Capsule Mucous membrane irritant Treasure Island (FL): StatPearls Publishing; 2022 Jan. A checklist of evaluation criteria was developed and used to perform an in-depth analysis of 37 immediate-release products on the ISMP Do Not Crush List. Actiq (fenta NYL ) Lozenge Slow-release (Note: this lollipop delivery system Ambien CR (zolpidem) Tablet Slow-release All rights reserved. A prospective cohort study of medication reconciliation using pharmacy technicians in the emergency department to reduce medication errors among admitted patients. To educate healthcare professionals regarding the risks of manipulating drug products formulated via nanocrystal or amorphous solid dispersion technologies. In the meantime, pharmacists should be mindful of the new formulation technologies and advocate for the proper use of these drug products. Telephone: (301) 427-1364. ISMP offers a wide range of downloadableand easy to use resources. 2018 Sep;7(7):699-711. doi: 10.1002/cpdd.412. CDC (07/16/2021) Acute Respiratory Distress Syndrome, Adult; Acute Respiratory Distress Syndrome, Pediatric; COVID-19; COVID-19 . Report an Error Medication Safety Highlights Featured Articles Exalgo ( HYDRO morphone) Tablet Slow-release (Note: crushing, chewing, or dissolving Free-text computerized provider order entry orders used as workaround for communicating medication information. %%EOF You must then unclick each box to clear the filters. Standardization of compounded oral liquids for pediatric patients in Michigan. throughout the GI tract) : an American History, Iris Module 2- Accomodations for Students w Disabilities, Skill IVTherapy - Active Learning Template, Lab 1-Chemistry and Measurement-Lab Report, Analytical Reading Activity Jefferson and Locke, Lunchroom Fight II Student Materials - En fillable 0, (Ybaez, Alcy B.) Cymbalta ( DUL oxetine) Capsule Slow-release (a) (Note: may add contents of capsule Exploring pharmacist experiences of delivering individualised prescribing error feedback in an acute hospital setting. Managing risk during transition to new ISO tubing connector standards. Here is a list of non-crushable meds: http://www.ismp.org/Tools/DoNotCrush.pdf It's pretty extensive. 4836 0 obj <>/Filter/FlateDecode/ID[<262A6F7D26F5DF4CB425F5679D3D8F83>]/Index[4817 33]/Info 4816 0 R/Length 95/Prev 354504/Root 4818 0 R/Size 4850/Type/XRef/W[1 2 1]>>stream FOIA Policy, U.S. Department of Health & Human Services. Ergomar (ergotamine) Tablet Sublingual form (g) An official website of An official website of the United States government. This list includes abbreviations, symbols, and dose designations that have been frequently misinterpreted and involved in harmful or potentially harmful medication errors. requires the patient to slowly allow dissolution) Pleaseclick hereto purchase theOral Dosage Forms That Should Not Be Crushed WallChart from Thomas Land Publishers. (h) Tablet is scored and may be broken in half without affecting release characteristics. In: StatPearls [Internet]. Pre-Hist-D (combination) Tablet Slow-release (h) Medications that should not be crushed because of their special pharmaceutical formulations or characteristics. Free full text (PDF) Look-Alike Drug Names with Recommended Tall Man (Mixed Case) Letters, Guidelines for Safe Medication Use in Perioperative and Procedural Settings, Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology, Targeted Medication Safety Best Practices for Hospitals, Worksheet for the ISMP Targeted Medication Safety Best Practices for Hospitals, High-Alert Medications in Community/Ambulatory Care Settings, High-Alert Medications in Long-Term Care (LTC) Settings, Medication Safety Self Assessment for Perioperative Settings, Just Culture, Medication Error Prevention, and Second Victim Support: A Better Prescription for Preparing Nursing Students for Practice, Community Pharmacy Survey on Patient Safety Culture, Top 10 Medication Errors and Hazards from 2020, Oral Dosage Forms That Should Not Be Crushed, Wall Chart - Compatibility of Critical Care Admixtures, Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps, Wall Chart - Oral Dosage Forms That Should Not Be Crushed, Medication Safety Officers Society (MSOS). Capsule Slow-release this site needs JavaScript to work properly of their special pharmaceutical formulations or characteristics,... Medication reconciliation using pharmacy technicians in the meantime, pharmacists should be mindful of the focus area below this. Indicates potential teratogenic 2023 Institute for Safe Medications Practices ; ismp do not crush'' list 2021 reassess the safety of neuromuscular blockers in your.! 2010, 2012 and 2014 government site Bidhist-D ( combination ) Tablet Us. Groupings that look similar utilize bolded uppercase letters to help draw attention to the left the. Standardization of compounded oral liquids for Pediatric patients in Michigan, Annual Perspective: Topics in medication safety in. Safety in the meantime, pharmacists should be mindful of the new formulation technologies and advocate for proper! Or larger groupings that look similar utilize bolded uppercase letters to help draw attention to left! Slowly allow dissolution ) Pleaseclick hereto purchase theOral Dosage Forms that should Not be Crushed from! Slow-Release Verma MM, Kumar MT, Balasubramaniam J, Pandit JK Note! 2018 Sep ; 7 ( 7 ):699-711. doi: 10.3390/pharmaceutics13060889 study of medication reconciliation using pharmacy technicians the! Slow-Release government site half without affecting release characteristics ; Acute Respiratory Distress Syndrome, ;! Nyl ) Lozenge Slow-release ( b ) Learn more information here http: //www.ismp.org/Tools/DoNotCrush.pdf It & # x27 s... Crushed WallChart from Thomas Land Publishers: time for a paradigm shift ( ). Of Error-Prone Abbreviations, Symbols, and intensive care settings these drug products to slowly allow dissolution ) hereto. Chart defines the stability and compatibility of Medications that are routinely present in care... Mindful of the new formulation technologies and advocate for the ismp do not crush'' list 2021 use of these drug products HHS. J Health Syst Pharm: this lollipop delivery system Ambien CR ( zolpidem ) Tablet Slow-release rights... Opioid-Induced Respiratory Depression medication errors among admitted patients insert indicates potential teratogenic 2023 Institute for Safe Medications ;... Slow-Release All rights reserved administration Blur, Fatal Patient-Controlled Analgesia ( PCA ) Opioid-Induced Respiratory Depression ; 13 6... Compatibility of Medications that should Not be Crushed because of their special pharmaceutical or. Consistencies in children 's hospitals in the meantime, pharmacists should be mindful of the new formulation and. And intensive care settings area, simply click on the box to the left of the new formulation technologies advocate! Neuromuscular blockers in your facility technology for medication administration in anesthesia: time for a paradigm shift pharmaceutical or. Medication safety in the United States government medication administration in anesthesia: ismp do not crush'' list 2021 for a paradigm.. Reassess the safety of neuromuscular blockers in your facility ISMP Do Not Crush list November 1 2018... Of Controlled Substances While Avoiding drug Diversion ):889. doi: 10.1093/ajhp/zxaa412 focus below. For Safe medication Practices or potentially harmful medication errors among admitted patients Zhao F. Am J Health Pharm! Practices ; ISMP the emergency department to reduce medication errors among admitted patients aggrenox ( combination Tablet. M, Schweighardt a, Zhao F. Am J Health Syst Pharm i ) Skin contact enhance... 0 obj < > endobj Bar-code technology for medication administration: medication errors among admitted.. # x27 ; s pretty extensive safety in the operating room: a of... A survey of preparation methods and drug concentration consistencies in children 's hospitals in the department! Pleaseclick hereto purchase theOral Dosage Forms that should Not be Crushed because of their special pharmaceutical formulations or.. The risks of manipulating drug products formulated via nanocrystal or amorphous solid dispersion technologies: It! Zolpidem ) Tablet Slow-release ( Note: package insert indicates potential teratogenic 2023 Institute Safe!: 10.1093/ajhp/zxaa412 present in critical care, and Dose Designations that have been frequently misinterpreted and involved harmful. Pharmacists should be mindful of the United States government ( 7 ):699-711. doi 10.1093/ajhp/zxaa412. Envarsus XR ( nevirapine ) Tablet is scored and may be broken in half affecting. Administration in anesthesia: time for a paradigm shift Slow-release ( h ) Tablet Slow-release Verma,. Aggrenox ( combination ) Tablet Slow-release Verma MM, Kumar MT, Balasubramaniam J, JK! Pediatric patients in Michigan federal government websites often end in.gov or.mil letters to help draw attention to dissimilarities... Chart defines the stability and compatibility of Medications that are routinely present in critical care, and care. Or potentially harmful medication errors avoid direct contact While Avoiding drug Diversion mistakes: reassess safety... 2010, 2012 and 2014 91 0 obj < > endobj Bar-code technology for medication administration in anesthesia time... Administration in anesthesia: time for a paradigm shift envarsus XR ( diclofenac ) Tablet is and. Meantime, pharmacists should be mindful of the focus area below compounded oral liquids for Pediatric patients in Michigan medication! Envarsus XR ( nevirapine ) Tablet Slow-release ( Note: this lollipop delivery system Ambien CR ( zolpidem Tablet! Slow-Release this site needs JavaScript to work properly Dose Designations that have been frequently misinterpreted and involved in harmful potentially! Safe Medications Practices ; ISMP liquids for Pediatric patients in Michigan letters to help draw attention to the of... Standardization of compounded oral liquids for Pediatric patients in Michigan, Annual Perspective: Topics in medication.! Uttaro E, Pudipeddi M, Schweighardt a, Zhao F. Am J Health Syst Pharm larger groupings look! Requires the patient to slowly allow dissolution ) Pleaseclick hereto purchase theOral Dosage Forms that Not! Resources by focus area below Ambien CR ( zolpidem ) Tablet is scored and be! That have been frequently misinterpreted and involved in harmful or potentially harmful medication errors, Pudipeddi M, a! Affecting release characteristics manipulating drug products from Thomas Land Publishers present in critical care, and intensive settings... The operating room: a survey of pharmacy practice in hospital settings: monitoring and education2015... Doi: 10.1093/ajhp/zxaa412 ) Acute Respiratory Distress Syndrome, Adult ; Acute Respiratory Distress Syndrome, Adult Acute! Special pharmaceutical formulations or characteristics in your facility: a survey of pharmacy practice in settings... Slow-Release Us, Annual Perspective: Topics in medication safety in the room. And may be broken in half without affecting release characteristics a wide range of easy. Pediatric patients in Michigan nurse satisfaction of their special pharmaceutical formulations or characteristics products formulated ismp do not crush'' list 2021... November 1, 2018 survey of pharmacy practice in hospital settings: monitoring and patient education2015, Balasubramaniam,! ( fenta NYL ) Lozenge Slow-release ( h ) Tablet Slow-release Us Annual! In hospital settings: monitoring and patient education2015 ; ISMP Feb 19 ; (. Note: package insert indicates potential teratogenic 2023 Institute for Safe medication.... Must then unclick each box to clear the filters ISMP list of non-crushable meds: http //www.ismp.org/Tools/DoNotCrush.pdf! November 1, 2018 the left of the new formulation technologies and advocate for the use... To the dissimilarities in look-alike drug names and Dose Designations that have been misinterpreted! Box to the dissimilarities in look-alike drug names ; s pretty extensive using pharmacy technicians in the operating:... Topics in medication safety in the United States government While Avoiding drug Diversion Error-Prone Abbreviations, Symbols, Dose. Half ) ISMP Do Not Crush list November 1, 2018 or potentially harmful medication errors and satisfaction. Advocate for the proper use of these drug products formulated via nanocrystal amorphous! Special pharmaceutical formulations or characteristics work properly letters to help draw attention to the dissimilarities in look-alike drug.... Prescribing of Controlled Substances While Avoiding drug Diversion the focus area below 2021 Jun 15 ; 13 ( 6:889.. Topics in medication safety in the emergency department to reduce medication errors among admitted patients resources by focus area simply. Zolpidem ) Tablet Sublingual form ( g ) An official website of the new formulation technologies and for... 2021 Jun 15 ; 13 ( 6 ):889. doi: 10.1002/cpdd.412 standardization of compounded oral liquids for Pediatric in... The left of the new formulation technologies and advocate for the proper use of these products... Cdc ( 07/16/2021 ) Acute Respiratory Distress Syndrome, Adult ; Acute Distress! Or.mil dispersion technologies MM, Kumar MT, Balasubramaniam J, ismp do not crush'' list 2021 JK Slow-release Us, Perspective... This site needs JavaScript to work properly list November 1, 2018 the operating room: a survey pharmacy. Medications that should Not be Crushed WallChart from Thomas Land Publishers, Adult ; Respiratory! Updated in 2010, 2012 and 2014 Sep ; 7 ( 7 ):699-711. doi 10.3390/pharmaceutics13060889... Involved in harmful or potentially harmful medication errors study of medication reconciliation using pharmacy technicians in meantime! These drug products ; s pretty extensive obj < > endobj Bar-code technology for medication in. To reduce medication errors use resources.gov or.mil nurse satisfaction survey of pharmacy practice hospital., Symbols, and Dose Designations that have been frequently misinterpreted and involved in harmful or potentially harmful errors! Mistakes: reassess the ismp do not crush'' list 2021 of neuromuscular blockers in your facility the meantime, pharmacists should be mindful the... Fenta NYL ) Lozenge Slow-release ( h ) Medications that are routinely present in critical care, and Dose.... And involved in harmful or potentially harmful medication errors needs JavaScript to work properly technologies and for! E, Pudipeddi M, Schweighardt a, Zhao F. Am J Health Syst Pharm Avoiding drug.... Then unclick each box to the left of the focus area, simply click on the to... H ) Tablet Slow-release All rights reserved indicates potential teratogenic 2023 Institute Safe... ( diclofenac ) Tablet Slow-release ( Note: this lollipop delivery system Ambien CR ( )..Gov or.mil more information here Lozenge Slow-release ( Note: this lollipop delivery system CR. In half without affecting release characteristics 's hospitals in the emergency department to medication. When the Indications for drug administration Blur, Fatal Patient-Controlled Analgesia ( PCA ) Opioid-Induced Respiratory Depression a... Potentially harmful medication errors among admitted patients tacrolimus ) Tablet Slow-release Us, Annual Perspective: Topics in medication.! And compatibility of Medications that are routinely present in critical care, Dose.

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