ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2024 Single Issues

Volume 22, Issue 1

In this issue:

• Ensuring Competency and Safety When Onboarding Newly Hired Professional Staff – Part I
• Worth repeating… Overwrap prevents barcode scanning
• what’s in a Name? The “-vastatin” drug stem name
• FDA warns of serious reaction to anti-seizure medications
• Confusion over sterility of povidone-iodine solution
• Obtain 1 hour of FREE nursing CE 

Volume 22, Issue 2

In this issue:

• The Role of Simulation When Onboarding Healthcare Professionals – Part II
• ISMP List of High-Alert Medications recently updated
• Process for using Merck’s new prefilled diluent syringe is error prone
• Influenza vaccine mistaken as diluent meant for respiratory syncytial virus (RSV) vaccine

Volume 22, Issue 3

In this issue:

• Microlearning – Bringing Bite-Sized Heparin Education to Nursing Units
• Safe drug administration during fasting
• what’s in a Name? The “curium/-curonium” stem name
• No, not three lidocaine patches at a time!
• Join us in celebrating…Patient Safety Awareness Week, March 10-16, 2024

Volume 22, Issue 4

In this issue:

• Patient Death Tied to Lack of Proper Escalation Process for Barcode Scanning Failures
• Your Reports at Work: FDA requires updates to promethazine labeling
• Accidental overdoses and adverse effects from compounded GLP-1 agonists
• Incomplete verbal order leads to wrong dose

Volume 22, Issue 5

In this issue:

• Minimizing Distractions and Interruptions During Medication Safety Tasks
• How fast is too fast for IV push medications?
• what’s in a Name? The “-gepant” drug stem name
• Top 10 patient safety concerns for 2024 
• Be a Nurse Leader at ISMP! 
• Join us in celebrating Nurses Week May 6-12, 2024

Volume 22, Issue 6

In this issue:

• Recent Look-Alike Errors with MYXREDLIN Put Patients at Risk
• Sharing a good catch prevented a future error
• Kentucky law prevents practitioners from being criminally charged for medical errors
• Share your safety stories with us

Volume 22, Issue 7

In this issue:

• Patient Death After Inadvertent Infusion of PRN Medication Hanging on Bedside Intravenous (IV) Pole
• Demo product found in a code cart tray
• Delay finding calcium chloride syringe due to yellow color association
• Spike separating from the port of WG Critical Care infusion bags

Volume 22, Issue 8

In this issue:

• Drug Diversion Prevention Beyond Controlled Substance Medications
• Sidebar: Is your organization’s medication surveillance system positioned to detect foul play?
• what’s in a Name? The “-tadine” drug stem name
• Worth repeating…

Volume 22, Issue 9

In this issue:

• The Dark Side – Safety Issues When Protecting Medications from Light
• what’s in a Name? The “-caine” drug stem name
• Warning! Manufacturer’s dexmedeTOMIDine premixed intravenous (IV) bags may be packaged in an overwrap labeled as acetaminophen!
• Magnesium sulfate almost administered instead of dexmedeTOMIDine
• Dialysis bags may rupture during mixing

Volume 22, Issue 10

In this issue:

• Total Systems Safety Supports Practitioners in Partnering with Families to Protect Patients
• what’s in a Name? The “-ac” drug stem name
• Do not confuse these respiratory syncytial virus (RSV) products
• Only PRIORIX diluent was administered
• Vaccine registry not checked before administration

Volume 22, Issue 11

In this issue:

• Patients with Low Health Literacy Make More Errors Interpreting Instructions and Warnings
• Some products continue to present risks of needlestick injuries
• Hurricane Helene intravenous (IV) fluid update

Volume 22, Issue 12

In this issue: