ISMP Medication Safety Alert!® Acute Care Newsletter - 2020 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 25, Issue 1
In this issue:
- Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards
- Barcodes on curved surfaces
- Potential mix-ups between Aimovig strengths and packages
- Fatal route of administration mistakenly recommended in journal article
- Nizatidine confused with tiZANidine
- Special thanks to our 2019 MSOS Briefings presenters
Volume 25, Issue 2
In this issue:
- Medical Abbreviations That Have Contradictory or Ambiguous Meanings
- Waste and error risk tied to Stivarga packaging
- Caution: Look-alike, sound-alike drug name pairs
- Your Reports at Work: Udenyca and Prolia
- Acute Care Action Agenda (October – December 2019)
Volume 25, Issue 3
In this issue:
- Errors Associated with Oxytocin Use: A Multi-organization Analysis by ISMP and ISMP Canada
- Now available from ISMP: Expanded Smart Pump Guidelines
- Problems with containers with dual linear barcodes
- Be prepared for coronavirus
- Rocuronium peel-off label shows amount per mL not per vial
- Unsafe product labeling
Volume 25, Issue 4
In this issue:
- Two New Best Practices in the 2020-2021 Targeted Medication Safety Best Practices for Hospitals
- Methadone overdose linked to scanning the wrong barcode
- Should the PillCrusher syringe be used for crushing tablets?
- Teva look-alike labels
- Careful where you place those stickers!
- ISMP survey on the Two New 2020-2021 Targeted Medication Safety Best Practices for Hospitals
Volume 25, Issue 5
In this issue:
- Do You Know What Doses Are Being Programmed in the OR? Make it an Expectation to Use Smart Infusion Pumps with DERS
- You need to relabel this generic insulin pen
- Potential harm from tablet mix-ups due to similar imprints and appearance
- View FREE COVID-19 webinar
- Patient Safety Awareness Week: March 8-14, 2020
- ISMP Medication Safety Self Assessment® for Perioperative Settings – Coming this Fall! (look for more information about this new assessment tool this summer)
Volume 25, Issue 6
In this issue:
- Special Edition: COVID-19
- Revisiting the Need for MDI Common Canister Protocols During the COVID-19 Pandemic
- Limit Use and Protect Supplies of Unproven but Widely Prescribed COVID-19 Treatment
- COVID-19 Collaboration
- Worth visiting…
Volume 25, Issue 6 (Supplement)
In this issue:
- Clinical Experiences Keeping Infusion Pumps Outside the Room for COVID-19 Patients
- ECRI: Considerations for using infusion pumps outside of patient rooms
- COVID-19 Collaboration
- Gravity flow rate drip chart (B.Braun)
Volume 25, Issue 7
In this issue:
- Planning for Anticipated Shortage of Smart Infusion Pumps and Dedicated Administration Sets
- Patient taking hydroxychloroquine right after discontinuing azithromycin develops QTc prolongation and cardiac arrest
- Healthcare Workers are our HEROS
- COVID-19 Collaboration
- Worth visiting…
- Gravity flow rate drip chart (B.Braun)
Volume 25, Issue 7 (Supplement)
In this issue:
- Considerations for Automated Dispensing Cabinet (ADC) Usage During COVID-19
- Need for standardizing critical care drug infusions has never been greater
- COVID-19 Frequently Asked Questions
- Share your stories of support
- COVID-19 Collaboration
Volume 25, Issue 8
In this issue:
- Error-Prone Dose Expression on Label of Unapproved Drug, Ascorbic Acid, from Mylan
- Highlights of a COCA (Clinical Outreach and Communication Activity) webinar on insights from two health systems impacted by COVID-19
- COVID-19 Collaboration
- Worth visiting…
- Acute Care Action Agenda (January – March 2020)
Volume 25, Issue 8 (Supplement)
In this issue:
- Leadership Support is Vital: If We Fail to Support Caregivers, There Will Be Few Left to Support Care
- Not all superheroes wear capes: National Nurses Week: May 6-12, 2020
- COVID-19 Collaboration
- Worth visiting…
Volume 25, Issue 9
In this issue:
- Incorrect Use of Smart Infusion Pump in the Operating Room (OR) Leads to Milrinone Overdose
- Patients who come to the hospital with unit-of-use-type packaging
- Rabies immune globulin carton label improved
- Special Alert! Short period of Surescripts medication history inaccuracies
- Selenious acid product labeled in terms of active moiety
Volume 25, Issue 9 (Supplement)
In this issue:
- COVID-19-Related Medication Errors
- COVID-19 Collaboration
Volume 25, Issue 10
In this issue:
- Subtherapeutic Heparin Infusions: Is Your Organization at Risk of Bypassing Soft Low-Dose Alerts?
- NYMALIZE formulation and packaging change
- Confusion with VENCLEXTA unit dose package label continues
- Barcode scan workaround leads to error
- Lidocaine cardiac dose given instead of analgesic dose
- Join ISMP in celebrating National Nurses Month in May 2020
Volume 25, Issue 11
In this issue:
- Education is “Predictably Disappointing” and Should Never be Relied Upon Alone to Improve Safety
- Special Alert! Prepare for vials of neuromuscular blocking agents without cap warnings
- ISMP now accepting nominations for Cheers Awards
Volume 25, Issue 12
In this issue:
- The Differences Between Human Error, At-Risk Behavior, and Reckless Behavior are Key to a Just Culture
- Double concentration (2%) propofol now available
- FDA removes syringe administration from vinCRIStine labeling
- BD will not market an ISO 80369-3 compliant enteral syringe
- GEDSA members delay phase out of legacy enteral systems
- The KIDs List
- ISMP now accepting nominations for CHEERS AWARDS
Volume 25, Issue 13
In this issue:
- Inappropriate FentaNYL Patch Prescriptions at Discharge for Opioid-Naïve, Elderly Patients
- Update on Omnicell variable character search feature
- Reminder: Time to end vinCRIStine syringe administration
- Letting the docs dispense
- Nymalize oral syringe to be adapted for ENFit
Volume 25, Issue 14
In this issue:
- NRFit: A Global “Fit” for Neuraxial Medication Safety
- Use brand names to help differentiate tacrolimus formulations
- Name confusion with rapid-acting insulins
- HUMANTE-P potency data shift on label leads to confusion
- Acute Care Action Agenda (April – June 2020)
Volume 25, Issue 15
In this issue:
- Survey Shows Room for Improvement with Two New ISMP Targeted Medication Safety Best Practices
- Can a product have two different expiration dates?
- FDA revises labeling for methotrexate tablets
- CORLANOR oral solution now available to hospitals
- ISMP survey on pharmacy compounding
Volume 25, Issue 16
In this issue:
- Compounded Sterile Preparation (CSP) Accuracy and Error Prevention Should Be Both a Leadership and Regulatory Mandate
- New trace element product available soon
- Your Reports at Work: New requirements for manufacturer expiration date format
- ECRI and ISMP to create a new joint PSO
- Use barcode scanning for inventory replacement
- WAKIX and LASIX name confusion
Volume 25, Issue 17
In this issue:
- During the Pandemic, Aspire to Identify and Prevent Medication Errors and to Avoid Blaming Attitudes
- Label improvements for MYXREDLIN
- That’s 15, not 50
- Prevent potential hydrALAZINE – hydrOXYzine mix-up
Volume 25, Issue 18
In this issue:
- FDA Advise-ERR: Reported Medication Errors with VEKLURY (remdesivir) Emergency Use Authorization
- NANALERT: Wrong-route tranexamic acid errors
- Easy for things to go wrong with test patients
- Close call because red font not visible on black and white printout
- Dexamethasone and dexmedetomidine confusion
- New concentration of methotrexate injection approved
- Proper dosing instructions for EpiPen and EpiPen Jr
Volume 25, Issue 19
In this issue:
- Analysis of Paramedicine Medication Errors Uncovers Challenges and Opportunities for Improvement
- Properly engage the orange needle protection device
- Which tall man letters should be used for dexmedetomidine?
- Update on phase-out schedule for legacy enteral systems
- Frequency of fentaNYL patch changes should match duration of drug delivery
- Pharmacy compounding survey extended
Volume 25, Issue 20
In this issue:
- Safety Investigations from Across the Pond: Deep Learning from England’s Healthcare Safety Investigation Branch (HSIB)
- Anticoagulant Citrate Dextrose Solution, Formula A (ACD-A) bags will have barcode, but not sure when
- Area to tear open patch wrapper can destroy the barcode
- Ready to use but not ready to administer
- Helping patients avoid insulin pen mix-ups
Volume 25, Issue 21
In this issue:
- ISMP Survey Provides Insights into Pharmacy Sterile Compounding Systems and Practices
- Heparin-hypertonic saline close call
- THRIV Coalition survey on IV workflow systems
- Mix-ups between droperidol and dronabinol
- Worth repeating… More mix-ups between ePHEDrine and EPINEPHrine
- Acute Care Action Agenda (July – September 2020)
- Join ISMP in Celebrating:
Volume 25, Issue 22
In this issue:
- ISMP Survey Provides Insights into Preparation and Admixture Practices OUTSIDE the Pharmacy
- Warning regarding strength listed on oxytocin vials
- Topical thrombin given systemically during bypass surgery
- Join ISMP in Celebrating:
- ISMP 23rd Annual Cheers Awards virtual event – December 8, 2020
Volume 25, Issue 23
In this issue:
- Learning from Influenza Vaccine Errors to Prepare for COVID-19 Vaccination Campaigns
- Infusion rate instructions for new COVID-19 monoclonal antibody
- VEKLURY (remdesivir) update
- New ASPEN recommendations for in-line filters for parenteral nutrition (PN)
- Update on Epic’s “fuzzy matching”
Volume 25, Issue 24
In this issue:
- Hidden Medication Loss When Using a Primary Administration Set for Small-Volume Intermittent Infusions
- Handling monoclonal antibodies from Lilly and Regeneron can be confusing
- Anatomy of a conventional vs. liposomal DOXOrubicin mix-up
- Administer adenosine rapidly for cardioversion
- Keep topical fluorouracil far away from pets
- ISMP Medication Safety Self Assessment for Perioperative Settings: Coming in early 2021!
Volume 25, Issue 25
In this issue:
- Building Bridges to Safety: ISMP 23rd Annual Cheers Awards
- Prevent shoulder injuries during COVID-19 vaccinations
- Naloxone, verapamil, and glycopyrrolate look-alike vials
- Error reporting mandatory for Emergency Use Authorization (EUA) drugs
- Paralyzing agent vial caps without warnings into 2022
- Tranexamic acid labeling changes coming
- The first five letters are not always enough
- Australia halts syringe use for vinCRIStine injection
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ISMP Medication Safety Alert!® Acute Care Newsletter - 2020 Single Issues
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ISMP Medication Safety Alert!® Acute Care Newsletter - 2020 Single Issues
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