The medication-use process and the importance of mastering fundamentals.

World Series. Game 6 was in the 10th inning when Mets player Mookie Wilson hit a ground ball toward first base and Red Sox first baseman Bill Buckner went to field it to end the inning. Instead, the ball went under Buckner’s glove, through his legs, and into the outfield, allowing the Mets to win that game and to come back the next day to win the World Series. That error cost the Red Sox the World Series and forever labeled Bill Buckner as the “goat” of the game, because he did not get his glove down on the ground, as taught to all Little Leaguers when they learn the fundamentals of fielding a ground ball. Today, health care delivery organizations, along with the pharmacy industry itself, are plagued by a similar set of circumstances. Errors are occurring because pharmacists are not following the fundamentals of filling prescriptions and dispensing medications. Pharmacy staff members are confusing drugs because of their sound-alike and look-alike names, and they are confusing brand-name products with generic bands—all because basic precautions are not being followed. This chronic problem led to the formation of the Institute for Safe Medication Practices (ISMP) more than 35 years ago.