Joint Hazard Alert! Action Needed to Address Incorrect Information on the Broselow Rainbow Tape

revised January 22, 2026 Institute for Safe Medication Practices (ISMP)American Society of Health-System Pharmacists (ASHP)Pediatric Pharmacy Association (PPA) The Broselow Rainbow Tape is a height...

NAN Alert! Manufacturer’s dexmedeTOMIDine premixed IV bags may be packaged within an overwrap labeled as acetaminophen

A Hikma product with an overwrap labeled acetaminophen injection 1,000 mg/100 mL (NDC 0143-9386-01,  lot  number  24070381, expiration date 09/2025) (Figure 1), may contain a dexmedeTOMIDine 400 m...

Isoflurane Labeled “For Animal Use Only” in Cartons of Isoflurane Intended for Human Use

ISMP has received reports from several healthcare institutions that recently received cardboard cases labeled “Isoflurane USP 100 mL” by Piramal Critical Care (NDC 66794-017-10) (Figure 1) that act...

NAN Alert! Potassium Chloride for Injection Concentrate in EXCEL Plastic Bags

B. Braun recently announced a new presentation of potassium chloride for injection concentrate (2 mEq/mL) in a 250 mL EXCEL container plastic bag with blue and red labeling, and a blocked medicatio...

Medication Safety Issues with Newly Authorized PAXLOVID

On December 22, 2021, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for PAXLOVID, consisting of oral tablets of nirmatrelvir that are co-packaged with oral t...

NAN Alert! Age-Related COVID-19 Vaccine Mix-Ups

Ever since the US Food and Drug Administration (FDA) authorized the emergency use of a specific formulation (10 mcg/0.2 mL) of the Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine for ch...

NAN Alert! Dangerous Wrong-Route Errors with Tranexamic Acid

We recently learned about three cases of accidental spinal injection of tranexamic acid instead of a local anesthetic intended for regional (spinal) anesthesia. Container mix-ups were involved in e...

Check for Proper Nucala Dose Preparation

If you are using NUCALA (mepolizumab) for patients who have eosinophilic asthma, please check to ensure the correct volume is being dispensed. In a Safety Brief in our June 28, 2018 newsletter, we ...

Severe Under Dosing of Insulin With U-500 Pen

An emergency department (ED) pharmacist was talking to a patient about his U-500 insulin dose. The patient, who had been using a U-500 insulin pen, told the pharmacist that his dose was 75 units b...

NAN Alert! Severe Hyperglycemia in Patients Incorrectly Using Insulin Pens at Home

The Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (MERP) has received several reports of patients who failed to remove the inner cover of a standard in...