ISMP Medication Safety Alert!® Acute Care Newsletter - 2024 Single Issues

Volume 29, Issue 1

In this issue:

• High-Alert Medication List for Acute Care Settings Updated for 2024
• Your Reports at Work: FDA requires updates to promethazine labeling
• B. Braun potassium chloride for injection concentrate pharmacy bulk package almost infused into patient
• Fluorouracil cream – ensure formulation corresponds to indication
• 2023 MSOS Member Briefings Presenters – Thank You!

Volume 29, Issue 2

In this issue:

• Be Wary of Controlled and Non-Controlled Medication Replicas Sold Online
• No, not three lidocaine patches at a time!
• Incomplete verbal order leads to wrong dose
• Just Culture Scholarship recipient and runners-up announced
• Acute Care Action Agenda (October – December 2023)

Volume 29, Issue 3

In this issue:

• The Dark Side – Safety Issues When Protecting Medications from Light
• Worth repeating… Respiratory Syncytial Virus (RSV) vaccines are not approved for children; AREXVY is not approved during pregnancy!
• ECRI top 10 health technology hazards for 2024
• Limit ketorolac therapy to 5 days

Volume 29, Issue 4

In this issue:

• Three New Best Practices in the 2024-2025 Targeted Medication Safety Best Practices for Hospitals
• Insulin dosing error close call due to look-alike syringe packaging
• Two phenazopyridine tablets packaged in a single unit dose blister
• Become an FDA/ISMP Fellow
• Join us in celebrating Patient Safety Awareness Week March 10-16, 2024

Volume 29, Issue 5

In this issue:

• Drug Diversion Prevention Beyond Controlled Substance Medications
• Worth repeating…SUMAtriptan injection wrong route errors continue
• Accidental overdoses and adverse effects from compounded GLP-1 agonists
• Safe drug administration during fasting
• Patient Safety Awareness Week March 10-16, 2024

Volume 29, Issue 6

In this issue:

• Implement Strategies to Prevent Persistent Medication Errors and Hazards: 2024
• Magnesium sulfate almost administered instead of dexmedeTOMIDine
• Fleet enemas, not as benign as they seem
• Poison Prevention Week March 17-23, 2024; Poison Help 1-800-222-1222

Volume 29, Issue 7

In this issue:

• Guardians of Grafts: Reducing Medication Errors in Transplant Recipients 
• Patient found unresponsive after Zosyn label placed on Myxredlin bag was infused
• Look-alike vials of Adrenalin and Retacrit
• Demo product found in a code cart tray 

Volume 29, Issue 8

In this issue:

• Patient Death After Inadvertent Infusion of PRN Medication Hanging on Bedside Intravenous (IV) Pole
• Confusion with preparation and infusion rates results in errors with bendamustine
• Delay finding calcium chloride syringe due to yellow color association
• Sharing a good catch prevented a future error
• Error-prone abbreviation list updated
• Acute Care Action Agenda (January – March 2024) 

Volume 29, Issue 9

In this issue:

• Utilizing Pharmacogenomic Testing Can Improve Medication Safety and Prevent Harm
• Patient received MYXREDLIN instead of CARDENE IV
• Errors when converting between salt and elemental dosages
• Spike separating from the port of WG Critical Care infusion bags
• Close call as a result of three-letter character search
• Be a Nurse Leader at ISMP!
• Nurses Week: May 6-12, 2024

Volume 29, Issue 10

In this issue:

• ISMP Urges Increased Action at the Practice Level to Halt the Growing Danger of Counterfeit Drugs
• Dialysis bags may rupture during mixing
• Kentucky law prevents practitioners from being criminally charged for medical errors
• New Website Coming Soon!

Volume 29, Issue 11

In this issue:

• Call to Action: Standardization and Smarter Logic Needed to Prevent Drug Name Selection Errors
• Worth repeating… More mix-ups between EPINEPHrine and ePHEDrine
• Are your organization’s surveillance systems positioned to detect foul play?
• ASHP USP <797> Activities

Volume 29, Issue 12

In this issue:

• Survey Shows Room for Improvement with Three New Best Practices for Hospitals
• Vials of 23.4% sodium chloride and calcium gluconate switched on automated compounder device
• Clotrimazole topical solution bottle resembles eye drops

Volume 29, Issue 13

In this issue:

• Total Systems Safety Supports Practitioners in Partnering with Families to Protect Patients
• Demo Dose updates forthcoming
• Keep your child safe: UpAndAway.org

Volume 29, Issue 14

In this issue:

• Cultivate Discussions in a Psychologically Safe Workplace – Part I
• NANALERT: Warning! Manufacturer’s dexmedeTOMIDine premixed IV bags may be packaged within an overwrap labeled as acetaminophen! 

Volume 29, Issue 15

In this issue:

• Psychologically Safe Workplace Enhances Root Cause Analysis Interviews – Part II
• Proactive assessment uncovered look-alike calcium gluconate and tranexamic acid bags
• Do not confuse eye wash solution with an enema
• Oral hydration products could be mistaken for intravenous (IV) use
• Acute Care Action Agenda (April – June 2024)

Volume 29, Issue 16

In this issue:

• Use Barcode Scanning to Prevent Errors with Enteral Nutrition Feedings
• Micafungin carton contains incorrect reconstitution concentration
• Do not rely on vial cap color for medication identification
• Judy Smetzer Just Culture Champion Scholarships: submit applications by September 28, 2024

Volume 29, Issue 17

In this issue:

• Can We Ensure Medication Safety with the Use of Speech Recognition Software?
• Message in our Mailbox: Pharmacists responding to codes
• New medical device for hypertension calls for risk-prone 1 liter sterile water for injection bags
• MethylPREDNISolone was almost administered instead of triamcinolone
• Judy Smetzer Just Culture Champion Scholarships: submit applications by September 28, 2024

Volume 29, Issue 18

In this issue:

• Implementation of Smart Infusion Pump Interoperability in the Emergency Department (ED)
• ExactaMix disposable inlets may contain particulates
• Oral agent packaged in a vial similar to an injectable
• World Patient Safety Day: September 17, 2024

Volume 29, Issue 19

In this issue:

• Safety Coaches Engage Staff to Report Medication Concerns and Promote Safe Behavior
• Pharmacy technician’s good catch via scanning prevented wrong drug error
• Patient almost given CARBOplatin instead of nivolumab

Volume 29, Issue 20

In this issue:

• Enhancing Medication Safety for Bariatric Surgery Patients
• Regadenoson glass syringes may be incompatible with needleless connectors
• Join us in celebrating... Pharmacy Technician Day on October 15, 2024

Volume 29, Issue 21

In this issue:

• ISMP National Vaccine Errors Reporting Program 2022-2023 Analysis: New Vaccines, New Errors
• Weathering the storm – Safety considerations during fluid shortages
• Using an irrigation syringe results in an overdose
• Welcome our newest staff members
• Join us in celebrating… National Pharmacy Week on October 20-26, 2024

Volume 29, Issue 22

In this issue:

• Survey Results Reveal Tubing Misconnections are Common and Underreported – Part I
• Fluid shortage update – Safeguard imported products
• Consider parenteral nutrition (PN) compatibility and stability data when applying USP <797> which accounts for sterility only
• Worth repeating…Do not push vancomycin
• Acute Care Action Agenda (July – September 2024) 

Volume 29, Issue 23

In this issue:

• Take Action to Prevent Tubing Misconnections – Part II
• Fatal route of administration mistakenly recommended in journal article
• Error when scanning FLUZONE barcode
• Child received an entire multiple-dose vial of COVID-19 vaccine
• Your Reports at Work: NYMALIZE oral solution now available in prefilled ENFit syringe

Volume 29, Issue 24

In this issue:

• Minimize Medication-Related Carbohydrates When a Ketogenic Diet Is Used for Seizure Control
• Imported glucose injection
• Methylene blue syringe markings could lead to dosing errors
• DexmedeTOMIDine almost administered instead of clindamycin
• Does IV push equate to IV bolus?
  

Volume 29, Issue 25

In this issue: