

ISMP Medication Safety Alert!® Community/Ambulatory Care Newsletter - 2023 Single Issues
The ISMP Medication Safety Alert!® Community/Ambulatory Care is a digital newsletter for healthcare practitioners in ambulatory settings, including community pharmacies, specialty pharmacies, outpatient clinics, physician offices, and state institutions.
Volume 22, Issue 1
In this issue:
- ISMP Updates Its List of Drug Names with Tall Man (Mixed Case) Letters Based on Survey Results
- Methotrexate multi-dose vial dispensed instead of single-dose vial
- ENFit patient resource guide
- Worth repeating...Ensure medications are properly reconstituted
- ISMP Medication Safety Alert! Action Agenda (September- December 2022)
Volume 22, Issue 2
In this issue:
- Shipping and Delivery Errors—Part I
- Enfamil multivitamin container labeling continues to cause concern
- Missing administration time impacts compliance packaging
Volume 22, Issue 3
In this issue:
- Pump Up the Volume: How to Prioritize Events and Analyze Error Data
- Hyoscyamine tablet labels look alike—verify formulation!
- Dispensing the correct quantity of somatropin
- Diluent from omeprazole kit given by itself
Volume 22, Issue 4
In this issue:
- ISMP Launches the 2023-24 Targeted Medication Safety Best Practices for Community Pharmacy
- Handling error with etoposide leads to wasted drug
- Pharmacist compounded minoxidil instead of Minoxidin
- Communicate Paxlovid expiration date extension to patients
- Another apparent mix-up between clomiPHENE and clomiPRAMINE
- Fewer high-alert drugs prescribed by dentists
Volume 22, Issue 5
In this issue:
- Shipping and Delivery Errors - Part II
- Posaconazole packets and kit require patient education
- Look-alike manufacturer bottles
- Wrong label placed on antibiotic
- ISMP Medication Safety Alert! Action Agenda (January - April 2023)
- New! ISMP Foundations in Medication Safety: Community Pharmacy
Volume 22, Issue 6
In this issue:
- Design Systems to Manage REMS Programs and Maximize Their Potential to Reduce the Risk of Errors
- Methotrexate injection dispensed without syringes and appropriate dosing information
- Educate patients about DisposeRx packets
- Some prefilled syringes still pose risk of needlestick injuries
- Preventing errors related to vaccine storage
- Welcome to our newest ISMP staff member! Jennifer Young, PharmD, BCPS, CSP
Volume 22, Issue 7
In this issue:
- Ensuring Competency and Safety When Onboarding Newly Hired Professional Staff
- Meds-to-Beds drug omission related to alternate point-of-sale workflow
- Mix-ups between look-alike timolol eye drop formulations
- Wrong TEZSPIRE device dispensed
- Device manufacturers must standardize to the metric system
- Coming soon: Applications for the Judy Smetzer Just Culture Champion Scholarships open August 1, 2023.
Volume 22, Issue 8
In this issue:
- Prevent Administration of Ear Drops into the Eyes
- Education in proper use of insulin pen needles is needed
- Lost in translation
- The first 5 letters are not always enough
- Worth repeating...Mix-ups between BIKTARVY dosage strengths
- Welcome 2023-2024 Fellows
- Apply now for the Judy Smetzer Just Culture Champion Scholarships; applications due by September 28, 2023.
Volume 22, Issue 9
In this issue:
- Another Patient Death: Implement Strategies to Prevent Accidental Daily Methotrexate Dosing
- Confusing FLUZONE High-Dose packaging led to a double dose
- Wrong prescription bag given to patient
- New expiration date format is official
- ISMP Medication Safety Alert! Action Agenda (May - August 2023)
- Register now! MSI workshop for community, mail order, and specialty pharmacy
Volume 22, Issue 10
In this issue:
- New Error-Prone Situations after Vaccines Approved with Prefilled Diluent Syringes
- Unintentional ingestion of boric acid vaginal suppositories
- Moderna COVID-19 vaccine overfill leads to a double dose
- Changes in ZEJULA formulations contribute to errors
- Potential for mix-ups between TALVEY and TECVAYLI
- ISMP 26th Annual Cheers Awards
Volume 22, Issue 11
In this issue:
- Support Health Literacy to Enhance Medication Safety for Patients
- Don’t confuse products used to prevent infections from respiratory syncytial virus
- No, not always 3 lidocaine patches at a time!
- Humatrope pen and cartridge mismatch
- Worth repeating...Safeguard your return-to-stock (RTS) process
- ISMP 26th Annual Cheers Awards
Volume 22, Issue 12
In this issue:
- ISMP 26th Annual Cheers Awards: Hitting the Safety High Notes
- Take steps to prevent confusion with these names
- Worth repeating...Ensuring the safe use of automated dispensing technology
- Safeguard notification process when refrigerator temperatures deviate!
- Problematic TYLENOL packaging
- Fluorouracil cream—ensure formulation corresponds to indication
- Verify patient ID and open the bag

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