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White Paper

IV Push Medication Practices: Identifying Persistent Gaps and Advancing Safety

Rethinking IV push safety: what a decade of data tells us

Even after more than ten years of guidance from the ISMP Safe Practice Guidelines for Adult IV Push Medications, significant risks remain in preparation and administration practices. IV push medications act quickly in the body, leaving little margin for error, and frontline clinicians continue to face challenges that can lead to serious patient harm.

This white paper from Med Safety Board (MSB), powered by ECRI, draws on a national survey of over 400 clinicians and recent error reports to provide a comprehensive, evidence-based perspective on where IV push practices have advanced, where gaps persist, and what organizations can do to drive meaningful safety improvements.

Why this white paper matters now:

  • Illuminate persistent challenges: Understand the most common errors in IV push medication preparation and administration, from unnecessary dilution to improper labeling and wrong-rate administration.
  • Measure progress against historical benchmarks: Compare today’s practices with those from the past decade to identify trends and areas for targeted intervention.
  • Learn from real-world events: Case studies demonstrate how routine deviations or minor lapses can quickly escalate into critical patient safety events.
  • Gain practical, cross-disciplinary guidance: Recommendations are not limited to nursing—they span healthcare organizations, drug manufacturers, and EHR vendors to advance system-wide safety.
  • Support strategic decision-making: Equip leadership with data-driven insights to prioritize investments, training, and policy improvements.

Who should read this white paper

This resource is designed for professionals responsible for medication safety, clinical practice, and system improvement, including:

  • Medication Safety Officers & Teams
  • Quality & Risk Management Leaders
  • Nursing Staff & Leadership
  • Pharmacy Staff & Leadership
  • Prescribers / Physicians
  • Drug Manufacturers
  • EHR Vendors

Gain authoritative insights, evidence-based findings, and actionable strategies to strengthen IV push medication safety, reduce error risk, and advance organizational excellence.

Download the White Paper