ISMP Medication Safety Alert!® Acute Care Newsletter - 2025 Single Issues

Volume 30, Issue 1

In this issue:

• MERP Annual Review Exposes How Manufacturer Labeling/Quality Issues Impact Medication Safety
• Entire insulin infusion administered at fluid rate
• Topical agent packaged similarly to an injectable vial
• Budesonide prescribed instead of bumetanide results in readmission
• Vaccine registry not checked before administration

Volume 30, Issue 2

In this issue:

• Do Not Cut Scopolamine or CloNIDine Patches to Deliver Partial Medication Doses
• Provide order clarity when medications are to be given in divided doses
• Do not use unapproved EPINEPHrine nasal solutions
• Incorrect concentration of dextrose infusions prepared during shortage
• Acute Care Action Agenda (October – December 2024)

Volume 30, Issue 3

In this issue:

• Another Case of Nursing Criminalization – Long-Term Care (LTC) Must Improve Systems, Not Blame Nurses – Part I
• Medication syringes may be mistaken for sodium chloride flush
• Lack of electronic health record (EHR) integration between health systems leads to incomplete medication lists
• Epoprostenol reconstituted incorrectly

Volume 30, Issue 4

In this issue:

• A Deeper Dive into Active Failures and Accountability Using Just Culture Principles – Part II
• Danziten and Tasigna are NOT interchangeable nilotinib formulations
• Magnesium almost administered instead of heparin
• Remembering James Reason
• Worth repeating… Patient developed methemoglobinemia after administration of Hurricaine spray

Volume 30, Issue 5

In this issue:

• Survey Exposes Risks with Custom and Multi-Chamber Parenteral Nutrition – Part I
• Infusion errors can still occur with interoperability
• Esmolol labeled as “DOUBLE STRENGTH” may lead to confusion

Volume 30, Issue 6

In this issue:

• Action Needed to Address Risk with Custom and Multi-Chamber Bag Parenteral Nutrition – Part II
• Syringe design hinders emergency medication delivery
• Manufacturer’s levETIRAcetam 1,000 mg/100 mL premixed IV bags mislabeled as 500 mg/100 mL
• Prevent intravenous lipid bag mix-up with ViperSlide
• PCC – Prothrombin complex concentrate or protein C concentrate?

Volume 30, Issue 7

In this issue:

• Implement Strategies to Prevent Persistent Medication Errors and Hazards: 2025
• Medication vial coring and fragmentation risks
• Your Reports at Work: Label changes help differentiate Amneal infusion bags
• Survey on Implementation of Targeted Best Practices

Volume 30, Issue 8

In this issue:

• Food-Drug Allergies – Inactive Ingredients Taking Active Roles
• Cyanokit – action needed!
• Alpha-gal syndrome – evaluate inactive ingredients
• Acute Care Action Agenda (January – March 2025)
  

Volume 30, Issue 9

In this issue:

• Respiratory Therapists Play a Critical Role in Medication Safety
• Never dilute medication in a syringe labeled as a saline flush
• More mix-ups with rifamycin antibiotics
• Changes to Hikma’s vancomycin reconstitution instructions

Volume 30, Issue 10

In this issue:

• Call to Action: Practitioners Need to Warn Patients About Purchasing Counterfeit Drugs Online
• DiazePAM 10 mg/2 mL prefilled syringe label design may result in incorrect dose
• Pink vial caps lead to close call with high-alert medications
  

Volume 30, Issue 11

In this issue:

• Do You Know What Is Going on in Your OR? The Anesthesiology Residents’ Perspective
• Formalin almost administered instead of sterile water
• Caution: Drug names that end with the letter “l”
• Close call with 0.9% and 3% sodium chloride bags
• EPINEPHrine auto-injector without retractable needle
  

Volume 30, Issue 12

In this issue:

• Prevent Potentially Catastrophic Drug Overdoses by Properly Configuring Various Technologies
• Multiple Barcode and Dates on Oxytocin Bags
• Hazard! Broselow Rainbow Tape contains incorrect information
• Paralytic agent mistaken for insulin
• Do not use non-sterile ultrasound gel for percutaneous procedures

Volume 30, Issue 13

In this issue:

• Lost in Transition: Evaluate and Mitigate Risks During Interfacility Transfers
• Is it ceFAZolin or penicillin G potassium?
• Abrysvo diluent syringe design hinders vaccine reconstitution

Volume 30, Issue 14

In this issue:

• Why Scan “Harmless” Saline Infusions and Flush Syringes? It Might Not be What You Think!
• Remembering Dr. Lucian Leape
• Topical medication in luer syringe was injected
• Hiberix diluent syringe administered as vaccine

Volume 30, Issue 15

In this issue:

• Time-Saving Bias – Time to Rethink the Need for Speed
• Your Reports at Work: Sandoz ceFAZolin recall
• Review and update parenteral nutrition order forms and order sets
• Updated guidelines for electronic communication
• Acute Care Action Agenda (April – June 2025)

Volume 30, Issue 16

In this issue:

• Enhance Interoperability Workflow and End User Alerts to Ensure Meaningful Action
• Contaminated WG Critical Care calcium gluconate 2,000 m g/100 mL bag
• Irrigation solution infused intravenously

Volume 30, Issue 17

In this issue:

• Take Action on the Top Five Themes Identified During ISMP Consultations
• Worth repeating…Patient given oral cromolyn via nebulizer – again!
• Warning! Overwrap labeled potassium chloride 10 mEq/100 mL may contain potassium chloride 20 mEq/50 mL premixed IV bag
• IV push propofol almost administered via amnioinfusion line

Volume 30, Issue 18

In this issue:

• Safeguard Pediatric Patients – Act Upon the 2025 KIDs List
• Another Potentially Contaminated Calcium Gluconate Bag – Now by Amneal
• Barcode Scanning Is Crucial to Prevent Mix-Ups with Similar-Looking Heparin Bags
• Norepinephrine Mistaken for Similar-Looking Vials of Multivitamin Injection

Volume 30, Issue 19

In this issue:

• Support Practitioners Through Second Victim Programs
• Priorix Packaging – Possibility of Diluent Being Given Without the Vaccine
• Methohexital Syringes Mistaken for Similar-Looking Ketamine

Volume 30, Issue 20

In this issue:

• Raising the Bar – Zoning in on Barcode Medication Administration Practices
• Titratable Infusions Call for an Interdisciplinary Approach
• Include Implantable Medication Pumps in Patients’ Medication Histories

Volume 30, Issue 21

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Volume 30, Issue 22

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Volume 30, Issue 23

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Volume 30, Issue 24

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Volume 30, Issue 25

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