ISMP Medication Safety Alert!® Acute Care Newsletter - 2024 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 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:
- ISMP 27th Annual Cheers Awards: Making Medication Safety Magic
- Child receives wrong drug due to proxy scan
- Fluid shortage update
- Do not confuse Neffy and Narcan nasal sprays
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