ISMP Medication Safety Alert!® Acute Care Newsletter - 2022 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 27, Issue 1
In this issue:
- 2022 Ushers in the Beginning of a New Era at ISMP
- Management of Drug Shortages with 0.9% Sodium Chloride, Sterile Water for Injection, and EPINEPHrine
- Potential for severe cardiovascular effects when restarting cloZAPine
- All about the slashed zero glyphs
- Look-alike tablets with nearly identical imprints
- Prasugrel unavailable in unit dose packaging
Volume 27, Issue 2
In this issue:
- Start the Year Off Right by Addressing These Top 10 Medication Safety Concerns from 2021
- Worth repeating… Preventing lipid injectable emulsion (ILE) and ViperSlide mix-ups
- Error involving PAXLOVID packaging
- Regular review of patient education material is essential
- Acute Care Action Agenda (October - December 2021)
Volume 27, Issue 3
In this issue:
- Three New Best Practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals
- CLINOLIPID (lipid injectable emulsion [ILE]) container label issue
- Do not dilute gray-capped Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine!
- Tubing spikes drop from intravenous (IV) bags in use
Volume 27, Issue 4
In this issue:
- Survey Suggests Disrespectful Behaviors Persist in Healthcare: Practitioners Speak Up (Yet Again) – Part I
- Avoid using TB (tuberculin) syringes with orange caps
- Nonspecific PRN (as needed) medication administration
- Infant deaths associated with medical tubing entanglement
- Azithromycin packaging confusion
Volume 27, Issue 5
In this issue:
- Addressing Disrespectful Behaviors and Creating a Respectful, Healthy Workplace – Part II
- Lacosamide label improvement needed
- Barcode needed for BluePoint enoxaparin blister package label
- Look-alike NexJect syringes
- Join us in celebrating Patient Safety Awareness Week during March 13-19, 2022!
Volume 27, Issue 6
In this issue:
- Analysis Identifies Multiple Common Causes of Norepinephrine Errors
- Confusion with FETROJA preparation instructions
- COMETRIQ listed on discharge form instead of CoQ10 (coenzyme Q10)
- ISMP Medication Safety Alert! Acute Care readership survey
Volume 27, Issue 7
In this issue:
- Criminalization of Human Error and a Guilty Verdict: A Travesty of Justice that Threatens Patient Safety
Volume 27, Issue 8
In this issue:
- Personal Practice Changes Practitioners Would Make after Learning Firsthand about Medication Errors at ISMP
- Wrong directions – mL instead of mg – provided on the prescription label of pediatric propranolol oral liquid
- Baxter ExactaMix automated compounding device valve set shortage
- Potential for mix-ups between EVUSHELD and IMFINZI
- Risky shortened drug names
- Preliminary comparative data workbook now available!
- Join us in celebrating Nurses Week, May 6-12, 2022 and Nurses Month, May 2022!
- Acute Care Action Agenda (January – March 2022)
Volume 27, Issue 9
In this issue:
- Survey Shows Room for Improvement with Three New Best Practices for Hospitals
- New ECRI and ISMP Headquarters
- AuroMedics etomidate, pantoprazole, and bupivacaine mix-ups
- Strategies for the ExactaMix valve set shortage
- Topical gel dispensed in an ENFit syringe given via G-tube
- FDA Announcement: PAXLOVID Checklist
- Join us in celebrating Nurses Week, May 6-12, 2022 and Nurses Month, May 2022!
Volume 27, Issue 10
In this issue:
- Are You Well Positioned to Resolve Conflicts with the Safety of an Order? Learning from a Physician’s Homicide Trial and the Firing of Multiple Healthcare Workers
- Patients swallowed the desiccants in everolimus blister cards
- NAN Alert! Potassium chloride for injection concentrate in EXCEL plastic bags
- ISMP relieved by Vaught sentence
- Safe practices during contrast media shortages
- Companies begin move toward full implementation of ENFit
- Atropine prefilled syringes with sealed syringe tips
Volume 27, Issue 11
In this issue:
- Adopt Strategies to Manage Look-Alike and/or Sound-Alike Medication Name Mix-Ups
- FDA Advise-ERR: Pen injectors need pen needles!
- PAXLOVID drug interaction
- EPRONTIA oral solution concentration conversion
- Different concentrations of oral liquid baclofen
- Just Culture scholarships
Volume 27, Issue 12
In this issue:
- A Comprehensive, Proactive Plan Is Needed to Mitigate Risk When Changing Drug Concentrations
- Newsletter Readers Act upon ISMP Recommendations
- US name and International Nonproprietary Name (INN) are different
- List of coronavirus disease 2019 (COVID-19) vaccine resources
- Lot number or expiration date?
- Your Reports as Work: Safety Consideration for Container Labels and Carton Labeling Design to Minimize Medication Errors
- Nominations open for Cheers Awards
Volume 27, Issue 13
In this issue:
- Numerous Wrong Dose Errors with PAXLOVID
- Additional risk of age-related mix-ups now that our youngest patients are eligible for coronavirus disease 2019 (COVID-19) vaccines
- Don’t confuse ePHEDrine hydrochloride with ePHEDrine sulfate
- Patient drank albuterol nebulization solution
- Fluconazole tablet blister pack without a barcode
- Look-alike phenylephrine and neostigmine vials and cartons
- ISMP survey for pharmacists when responding to codes
Volume 27, Issue 14
In this issue:
- Medication Orders with Future Start Dates: How Far Away Is Too Far?
- Coronavirus disease 2019 (COVID-19) vaccine package concerns
- Pharmacists can now prescribe PAXLOVID (nirmatrelvir and ritonavir) and need to be aware of error risks
- Potassium chloride for injection concentrate 250 mL bags reaching organizations
- Welcome to our newest ISMP staff member! Shannon Bertagnoli, PharmD, BCPPS
- Acute Care Action Agenda (April – June 2022)
Volume 27, Issue 15
In this issue:
- Prevent Uncontrolled, Rapid Infusion Rates: Confirm Infusions Are Connected to Pumps Before Opening the Clamp!
- Multi-chamber bag parenteral nutrition (MCB-PN) is not without risk
- Risk-prone scenarios with multi-trace products
- Black port cover added to B. Braun's potassium chloride for injection concentrate bag
- Observe for possible ExactaMix 2400 valve set port leakage
- Accidental needlestick with EVENITY prefilled syringe
- Hidden pork content in gelatin capsules
- USP expiration date format
- Worth repeating… Norepinephrine left in a discontinued intravenous (IV) line administered as a bolus
Volume 27, Issue 16
In this issue:
- An Interview: Success with Barcode Scanning to Enhance Perioperative Medication Safety
- Pfizer and the US Food and Drug Administration (FDA) respond to PAXLOVID (nirmatrelvir and ritonavir) error reports
- Risk of prescribing an overdose in athenahealth’s EHR (electronic health record)
- Look-alike MENACTRA and MENQUADFI (meningococcal conjugate vaccines) packages
- “Shellfish allergy” may be a red herring
- Meet our three new 2022-2023 Fellows
- ISMP perioperative guidelines are now available!
Volume 27, Issue 17
In this issue:
- Emergency Preparedness: Be Ready for Unanticipated Electronic Health Record (EHR) Downtime
- Confirm tenecteplase indication and dose before use
- Prescription drug monitoring programs (PDMPs) can identify duplicate opioid therapy
- Patient received pyridostigmine instead of physostigmine
Volume 27, Issue 18
In this issue:
- Explore Our Updated ConsumerMedSafety.org Website
- Trend shows increased nursing workload to address smart pump alerts for HYDROmorphone and fentaNYL infusions
- Message in our Mailbox: Barcode scanning by anesthesia providers in the operating room (OR)
- Scan before you flush
- Your Reports at Work: Important safety news for pets!
Volume 27, Issue 19
In this issue:
- ISMP National Vaccine Errors Reporting Program: 2020-2021 Analysis Focuses on Age-Related, Non-COVID-19 Vaccine Errors
- Bivalent COVID-19 vaccine vial label concerns
- Avoid tearing the metal flange on the monkeypox vaccine vial
- More on leaking ports with ExactaMix 2400 compounder
- ISMP 25th Annual Cheers Awards
Volume 27, Issue 20
In this issue:
- Survey Results from Pharmacists Provide Support to Enhance the Organizational Response to Codes
- Your Reports at Work: Elimination of orange-capped tuberculin (TB) syringes
- No expiration date on coronavirus disease 2019 (COVID-19) vaccine label
- STS abbreviation results in a close call
- Expanded access to adult vaccines
- Celebrate National Pharmacy Week: October 16-22, 2022
- Acute Care Action Agenda (July – September 2022)
Volume 27, Issue 21
In this issue:
- Safety Considerations for Challenges When Using Smart Infusion Pumps
- Paralytic cap warning is easily missed
- Worth repeating…
- 2023 Just Culture scholarship recipients
- Please take our survey on tall man letters!
- Celebrate National Pharmacy Week! October 16-22, 2022
- ISMP 25th Annual Cheers Awards
Volume 27, Issue 22
In this issue:
- California Medication Error Reduction Plan: Time for Regulators and Accreditors to Adopt Similar Initiatives
- Using Vaccinia Immune Globulin Intravenous (VIGIV) for monkeypox? The concentration is not as it may seem
- Survey about NRFit transition
- ISMP 25th Annual Cheers Awards
Volume 27, Issue 23
In this issue:
- Preventing Errors When Preparing and Administering Medications Via Enteral Feeding Tubes
- Your Reports at Work: New ready-to-use vaccine presentations do not require reconstitution
- Clarification about the Do Not Crush List
Volume 27, Issue 24
In this issue:
- Prevent Administration of Ear Drops into the Eyes
- Sulfa, sulfur, sulfite, and sulfate allergy confusion
- Prefilled glass syringes incompatible with certain needlefree connectors
- QuVa Pharma two-sided labels for intravenous (IV) bags
Volume 27, Issue 25
In this issue:
- ISMP’s 25th Annual Cheers Awards: Walking the Red Carpet with Safety Stars
- ROTARIX cap could pose a choking hazard
- Etoposide vial found in DOXOrubicin carton
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ISMP Medication Safety Alert!® Acute Care Newsletter - 2022 Single Issues
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ISMP Medication Safety Alert!® Acute Care Newsletter - 2022 Single Issues
Sale price$25.00
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