ISMP Medication Safety Alert!® Acute Care Newsletter - 2021 Single Issues
The ISMP Medication Safety Alert!® Acute Care is a digital newsletter for hospital healthcare professionals, including Directors of Pharmacy, Pharmacists, Nurses, Physicians, Medication and Patient Safety Officers, Risk Managers, or anyone concerned with medication safety.
Volume 26, Issue 1
In this issue:
- Learning from Errors with the New Coronavirus Disease 2019 (COVID-19) Vaccines
- Bamlanivimab confused with belimumab
- PIQRAY (alpelisib) labeling confusion
- Discard rufinamide oral suspension within 90 days of opening
- Thank You to our 2020 Medication Safety Officer Society (MSOS) Briefings presenters
- ISMP Safe Medication Management Fellowship: applications now being accepted
Volume 26, Issue 2
In this issue:
- Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020
- Assuring proper mixing of mycophenolate suspension
- More on preparation errors with Pfizer-BioNTech COVID-19 vaccine
- USP COVID-19 vaccine toolkit
- Additional COVID-19 resources
- Meet our 2020-2021 Fellows:
- Acute Care Action Agenda (October – December 2020)
Volume 26, Issue 3
In this issue:
- Updated Guidance Needed for Longstanding Large Volume Parenteral (LVP) Labeling and Packaging Problems
- Cisatracurium mislabeling incident calls for more efficient ways to alert the field
- Dosing errors with ENTRESTO
- Syringe with trailing zeros
- Dr. Allen Vaida retiring, Dr. Rita Jew joins staff
Volume 26, Issue 4
In this issue:
- A Recurring Call to Action: Every Healthcare Organization Needs a Medication Safety Officer!
- Error-prone concentrations of ibuprofen suspensions
- Dispense unit dose syringes using the most appropriate concentration
- Silicone-free syringes required
Volume 26, Issue 5
In this issue:
- Analysis of Transdermal Medication Patch Errors Uncovers a “Patchwork” of Safety Challenges
- Cisatracurium barcode is not scannable
- SIRVA (shoulder injury related to vaccine administration) persists
- PRAXBIND label information needs repositioning
- ASPEN-ISMP error-reporting project
- Your Reports at Work: Updated label for NOVOLOG Mix 70/30 generic equivalent
Volume 26, Issue 6
In this issue:
- Should FDA Reconsider Allowing the Pooling of COVID-19 Vaccine Doses to obtain Additional Doses?
- Vaccine card incorrect for single-dose COVID-19 vaccine
- Beware of COVID-19 vaccines sold online
- Reconstitution with alcohol instead of water
Volume 26, Issue 7
In this issue:
- Additional Strategies to Improve Complete Delivery of Small-Volume Intermittent Infusions
- Do not use Dr. Reddy’s prefilled glass naloxone syringes with a Clave/MicroClave connector
- Your Reports at Work: FIRVANQ diluent label revised
- One more reason to require scanning of flushes
- Two patients receive EPINEPHrine instead of COVID-19 vaccine
- Look-alike ophthalmic containers a long-standing problem
- Acute Care Action Agenda (January – March 2021)
Volume 26, Issue 8
In this issue:
- Any New Process Poses a Risk for Errors: Learning from 4 Months of Coronavirus Disease 2019 (COVID-19) Vaccinations
- Problems with Guangdong Haiou syringes for coronavirus disease 2019 (COVID-19) vaccinations
- URE-NA, not hydroxyurea
- Xylitol – toxic to dogs
- Confusing syringe scale
- Customized ISMP consulting services
Volume 26, Issue 9
In this issue:
- More Can Be Done to Alleviate Errors Associated with Pharmaceutical Product Labeling and Packaging
- Remembering Ronald S. Litman, DO. ML
- Compounding errors with bamlanivimab and etesevimab
- ZANTAC reborn
- Available May 18, 2021: ISMP Medication Safety Self Assessment for Perioperative Settings
Volume 26, Issue 10
In this issue:
- Just Culture, Medication Error Prevention, and Second Victim Support Needed in Nursing Curriculum
- Maximizing automated dispensing cabinet (ADC) medication removal and restocking accuracy
- Misconnection between cecostomy and gastrostomy
- Barcode scan indicates wrong drug
- Proper way to open MicroVault cover
- Please take our survey! 2020-2021 Targeted Medication Safety Best Practices for Hospitals
Volume 26, Issue 11
In this issue:
- Administration of Concentrated Potassium Chloride for Injection During a Code: Still Deadly!
- ADRENALIN (EPINEPHrine) vials look similar to coronavirus disease 2019 (COVID-19) vaccine vials
- Proper interpretation of expiration date format
- Confusing labeling on a two-dose blister
- Preferred vs. legal name of transgender patients
- Please take our survey! 2020-2021 Targeted Medication Safety Best Practices for Hospitals
Volume 26, Issue 12
In this issue:
- Identifying Color Additives in Regulated Drug Products
- How will PCA (patient-controlled analgesia) be administered to patients during an MRI (magnetic resonance imaging)?
- ISMP names a new medical director, Kelley Shultz, MD
- Unreadable expiration dates and barcodes
- “What happens if you give potassium chloride IV (intravenous) push?”
Volume 26, Issue 13
In this issue:
- Leaving a Discontinued FentaNYL Infusion Attached to the Patient Leads to a Tragic Error
- Close calls – a sign of resilience or vulnerability? Odds are higher that vulnerabilities are reported
- Infection transmission risk with shared glucometers, fingerstick devices, and insulin pens
- Confusion with INPEN devices
- Mix-ups between KETALAR and ketorolac
- Confirm correct mg and mL dose based on product concentration supplied
Volume 26, Issue 14
In this issue:
- Screening for Dihydropyrimidine Dehydrogenase (DPD) Deficiency in Fluorouracil Patients: Why Not?
- Patient administration errors with the use of alprostadil urethral inserts
- Improved safety needed for pediatric pegfilgrastim use
- Drug manufacturers need to stop printing barcodes across round surfaces!
- Deadline for new (perioperative) assessment extended to October 1, 2021!
- Acute Care Action Agenda (April – June 2021)
Volume 26, Issue 15
In this issue:
- Safety Committees Need to Proactively Address the Risk of Accidental Cerebral Injection of Intravenous (IV) Drugs
- Message in our Mailbox: Letter from NCCN (National Comprehensive Cancer Network)
- Inadvertent intra-arterial promethazine injury
- Manufacture of legacy feeding tubes ended
Volume 26, Issue 16
In this issue:
- TN Board of Nursing’s Unjust Decision to Revoke Nurse’s License: Travesty on Top of Tragedy!
- Weapon of mass destruction?
- Update on need for a pegfilgrastim formulation for pediatric dosing
Volume 26, Issue 17
In this issue:
- Pump Up the Volume: Tips for Increasing Error Reporting and Decreasing Patient Harm
- Keep up to date with Emergency Use Authorization (EUA) Fact Sheet changes
- Risks with leaving infusions connected to the patient
- Use “mcg,” not μg
Volume 26, Issue 18
In this issue:
- Disrespectful Behavior in Healthcare: Has It Improved?
- Outsourced paralyzing agent packaging could pose a serious safety issue
- Errata
- More on fluorouracil and pets
Volume 26, Issue 19
In this issue:
- Pharmacists’ and Nurses’ Role in Antimicrobial Stewardship, Antimicrobial Resistance, and Sepsis Care
- In loving memory of Hedy Cohen
- New packaging for REGEN-COV monoclonal antibodies may add confusion
- Eliminate bottles of phenol 80%
- Self Assessment (perioperative) deadline extended to December 10, 2021
Volume 26, Issue 20
In this issue:
- Mix-Ups Between the Influenza (Flu) Vaccine and COVID-19 Vaccines
- Worth repeating… NUCALA vial is overfilled for ease of reconstitution
- TRULICITY pen should never be primed
- COVID-19 revaccination for refugees or immigrants
- Meet our 2021-2022 Fellows:
- Acute Care Action Agenda (July – September 2021)
Volume 26, Issue 21
In this issue:
- Challenges with Requiring Five Characters During Automated Dispensing Cabinet (ADC) Drug Searches Via Override
- Potential for inaccurate medication history data
- FDA communication on the accuracy of ENFit low dose tip syringe
- Celebrate National Pharmacy Week – October 17-23, 2021
- Receive customized ISMP consulting services
- ISMP 24th Annual Cheers Awards virtual celebration – December 7, 2021
Volume 26, Issue 22
In this issue:
- Prevent Errors During Emergency Use of Hypertonic Sodium Chloride Solutions
- Adult and pediatric coronavirus disease 2019 (COVID-19) vaccine mix-ups are predictable
- Work continues to improve investigational drug labeling
Volume 26, Issue 23
In this issue:
- Multiple Error Pathways with the Monoclonal Antibodies, Casirivimab and Imdevimab
- Age-related COVID-19 vaccine mix-ups
- Safe use of parenteral nutrition
- Labeling of transdermal scopolamine products
- Dosing error (CRESEMBA [isavuconazonium sulfate])
- Submit perioperative self-assessment findings by December 10, 2021!
Volume 26, Issue 24
In this issue:
- Adverse Glycemic Events and Critical Emergencies
- Errors with injectable specialty medications
- Surprise! Not all drug labels have an NDC (National Drug Code)
Volume 26, Issue 25
In this issue:
- Path to New Beginnings: ISMP 24th Annual Cheers Awards
- NAN ALERT: Age-related coronavirus disease 2019 (COVID-19) vaccine mix-ups
- Potential problem opening imported HEXATRIONE ampules
- ONPATTRO requires a 0.45 micron filter for preparation
- Prasugrel unavailable in unit dose packaging
- Perioperative assessment: Final extension is February 11, 2022!
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