ISMP Medication Safety Alert!® Acute Care Newsletter - 2023 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 28, Issue 1
In this issue:
- Latent and Active Failures Perfectly Align to Allow a Preventable Adverse Event to Reach a Patient
- Worth repeating… Missing information on over-the-counter (OTC) liquid acetaminophen risks overdose
- Wrong route HYDROmorphone administration
- Become an ISMP Fellow
- Special Announcement: Isoflurane labeled “for animal use only” in cartons of isoflurane intended for human use
Volume 28, Issue 2
In this issue:
- ISMP Updates Its List of Drug Names with Tall Man (Mixed Case) Letters Based on Survey Results
- Inappropriate use of automated dispensing cabinet (ADC) overrides
- Pediatric strength BIKTARVY was accidentally prescribed and dispensed to adults
- Acute Care Action Agenda (October – December 2022)
- Become an ISMP Fellow
Volume 28, Issue 3
In this issue:
- Pump Up the Volume: How to Prioritize Events and Analyze Error Data
- Additional GIAPREZA concentration is available
- Follow VIVITROL preparation instructions to minimize clogged syringes
- Please take our survey on the Medication Error Reduction Plan!
Volume 28, Issue 4
In this issue:
- Controlled Substance Drug Diversion by Healthcare Workers as a Threat to Patient Safety—Part I
- Smudged IV bag label and a proxy scan set up a patient for a cardiac arrest
- Misprinted label on sodium chloride bag
- Safety issue with probiotic packaging
- Worth repeating… Never prepare oral or topical medications in a parenteral syringe!
- Quarterly ISMP Resources and Services Highlights
- Join us in Celebrating Patient Safety Awareness Week – March 12-18, 2023
Volume 28, Issue 5
In this issue:
- Controlled Substance Drug Diversion by Healthcare Workers as a Threat to Patient Safety—Part II
- Safety mechanism needed for EVENITY syringe needle to prevent needlestick injuries!
- Your Reports at Work: Heparin cardboard case label to include concentration
- Join us in Celebrating Patient Safety Awareness Week – March 12-18, 2023
Volume 28, Issue 6
In this issue:
- Implement Strategies to Prevent Persistent Medication Errors and Hazards
- BD Alaris Pump shut off and did not infuse vasopressors
- Be aware of error-prone abbreviations
- National Poison Prevention Week: March 19-25, 2023
Volume 28, Issue 7
In this issue:
- Safety Considerations During Expedited Product Approval
- Worth repeating… SUMAtriptan injection – it’s subcutaneous only!
- Death from air embolism after pneumatic tubing was connected to intravenous (IV) line
- Fewer high-alert drugs prescribed by dentists
- NEW – ISMP Targeted Medication Safety Best Practices for Community Pharmacy
Volume 28, Issue 8
In this issue:
- Ensuring Competency and Safety When Onboarding Newly Hired Professional Staff – Part I
- Incorrect lidocaine infusion option selected in smart pump drug library
- Acute Care Action Agenda (January – March 2023)
- Celebrate Nurses Month – May 2023
Volume 28, Issue 9
In this issue:
- The Role of Simulation When Onboarding Healthcare Professionals – Part II
- Survey results show implementing a medication error reduction plan (MERP) improves safety
- The Joint Commission takes a step backward
- Enfamil multivitamin labeling – easy to miss which product contains iron
Volume 28, Issue 10
In this issue:
- Smart Infusion Pump Investigations after an Unexplained Over-Infusion
- Communicate PAXLOVID expiration date extension to patients
- ISMP Survey on the 2022-2023 Targeted Medication Safety Best Practices for Hospitals
- ISMP Foundations in Medication Safety: Acute Care
Volume 28, Issue 11
In this issue:
- Taking a Closer Look at Medication Errors that Involve Oxytocin
- Remembering David Cousins, BPharm, MSc, FRPharmS, PhD
- Worth repeating… Errors continue with unsafe B. Braun intravenous (IV) bag labeling and difficult-to-scan barcodes
- ISMP Foundations in Medication Safety: Acute Care
Volume 28, Issue 12
In this issue:
- Assessing Medication Safety in Settings Not Designated Solely for Pediatric Patients
- FDA authorizes CISplatin importation from China
- Mix-ups between look-alike timolol eye drop formulations
Volume 28, Issue 13
In this issue:
- A Hard Look at Hard Stops and Workarounds in the Acute Care Setting
- Update on imported CISplatin
- Oral amiodarone loading dose continued for 8 months in error
- Automated dispensing cabinet (ADC) drug description leads to mannitol overdose
- ISMP/ECRI survey on drug, supply, and equipment shortages
Volume 28, Issue 14
In this issue:
- Proper Deployment of Risk Evaluation and Mitigation Strategy (REMS) to Reduce Potential Drug-Related Harm and Medication Errors – Part I
- Alcohol can remove label information
- Fluorouracil injection may precipitate
Volume 28, Issue 15
In this issue:
- Incorporating Risk Evaluation and Mitigation Strategy (REMS) Program Requirements into Systems and Processes – Part II
- Broken tamper-evident oral syringe cap
- Foiled again: Major Rugby barcode scanning issues
- Update on leaking ports with EXACTAMIX 2400 compounder
- Acute Care Action Agenda (April – June 2023)
- Coming soon: Applications for the Judy Smetzer Just Culture Champion Scholarships open August 1, 2023.
Volume 28, Issue 16
In this issue:
- Safety Issues with Long-Acting Injectable (LAI) Antipsychotics
- Lot number/expiration date a must for immediate container labels
- RYANODEX demo carton and vial look too much like the real thing
- Worth repeating… Education in proper use of insulin pen needles is needed
- Welcome 2023-2024 Fellows
- Apply now for the Judy Smetzer Just Culture Champion Scholarships; applications due by September 28, 2023.
Volume 28, Issue 17
In this issue:
- Obstetrical Patient Receives Ampule of Digoxin Instead of BUPivacaine for Spinal Anesthesia
- Worth repeating… Tranexamic acid wrong route errors continue
- Remembering Lawrence (Larry) Trissel, BS Pharm, FASHP
- Promotional materials can be confused with medicinal products
- Infuvite vials 1 and 2 have the same NDC and barcode
- Quarterly ISMP Resources and Services Highlights
- Device and technology resources available through HII-Tech
Volume 28, Issue 18
In this issue:
- Drug, Supply, and Equipment Shortages Continue to Compromise Patient Care
- Limitations of the most recent posaconazole formulation
- Confusing FLUZONE high-dose packaging
- Help ISMP update its list of high-alert medications
- Celebrate: World Patient Safety Day – September 17, 2023
Volume 28, Issue 19
In this issue:
- Patient Death Tied to Lack of Proper Escalation Process for Barcode Scanning Failures
- Worth repeating…FLUZONE packaging leads to a double dose
- Hazard Alert! Medisca 20 mL oral syringes could lead to dosing errors
- Some Cardinal Health Monoject syringes incompatible with syringe pumps
- The myth about the safety of the “Five Rights”
- Message in our Mailbox: Follow up on amiodarone dosing error
- Fatal N-acetylcysteine overdose due to pump programming errors
- ISMP 26th Annual Cheers Awards
Volume 28, Issue 20
In this issue:
- Minimizing Distractions and Interruptions During Medication Safety Tasks
- Potential for mix-ups between TALVEY and TECVAYLI
- Textbook errata (Extemporaneous Ophthalmic Preparations, Alghamdi, 2020)
- National Pharmacy Week: October 15-21, 2023
- ISMP 26th Annual Cheers Awards
Volume 28, Issue 21
In this issue:
- Temporarily Holding Medication Orders Safely in Order to Prevent Patient Harm
- Process for using Merck’s new prefilled diluent syringe is error prone
- Influenza vaccine mistaken as diluent meant for respiratory syncytial virus vaccine (RSV)
- Acute Care Action Agenda (July – September 2023)
- American Pharmacists Month: October 2023
- ISMP 26th Annual Cheers Awards
Volume 28, Issue 22
In this issue:
- Intravenous (IV) Push Medications – Bridging the Gap Between Education and Clinical Practice
- Moderna COVID-19 vaccine overfill leads to a double dose
- Look-alike vial labeling from a 503B outsourcing facility
- ISMP 26th Annual Cheers Awards
Volume 28, Issue 23
In this issue:
- Why “Benchmarking” Error Rates Is NEVER a Good Measure of Performance or Patient Safety
- Call to Action: Address pharmacy technician shortage or compromise safety
- Worth repeating…Overwrap prevents barcode scanning
- ISMP 26th Annual Cheers Awards
Volume 28, Issue 24
In this issue:
- Patients with Low Health Literacy Make More Errors Interpreting Instructions and Warnings
- Look-alike potassium phosphates and sodium chloride vials
- Do not confuse these respiratory syncytial virus (RSV) products
- Your Reports at Work: Cardinal Health recalls certain Monoject syringes
- Quarterly ISMP Resources and Services
- ISMP 26th Annual Cheers Awards
Volume 28, Issue 25
In this issue:
- ISMP 26th Annual Cheers Awards: Hitting the Safety High Notes
- Unintentional Oral Ingestion of Boric Acid Vaginal Suppositories
- Confusion over sterility of povidone-iodine solution
- 12-month prescriptions are not the answer to overwhelmed pharmacy staff
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