ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2025 Single Issues

Volume 23, Issue 1

In this issue:

• Do Not Cut Scopolamine or CloNIDine Patches to Deliver Partial Doses
• what’s in a Name? The “-prost” drug stem name
• Does intravenous (IV) push equate to IV bolus?
• Patient almost given CARBOplatin instead of nivolumab
• This is how bad things happen
  

Volume 23, Issue 2

In this issue:

• Survey Results Reveal Tubing Misconnections Are Common and Often Underreported – Part I
• B. Braun potassium chloride for injection concentrate almost infused into patient
• Use of an irrigation syringe results in an overdose

Volume 23, Issue 3

In this issue:

• Take Action to Prevent Tubing Misconnections and Patient Harm – Part II
• what’s in a Name? The “-grastim” drug stem name
• Worth repeating… SUMAtriptan wrong route errors continue
• A dexmedeTOMIDine infusion almost administered instead of clindamycin
• MethylPREDNISolone injectable suspension was almost administered instead of triamcinolone

Volume 23, Issue 4

In this issue:

• Another Nurse Criminally Charged—LTC Must Improve Systems, Not Blame Nurses—Part I
• Proxy scan leads to child receiving the wrong drug
• Nymalize oral solution now available in prefilled ENFit syringe
• Do not administer vancomycin via IV push
• Topical agent packaged similar to an injectable vial

Volume 23, Issue 5

In this issue:

• Using Just Culture Principles to Look More Closely at Active Failures and Accountability—Part II
• what’s in a Name? The “-estrant” drug stem name
• Possible confusion between Neffy and Narcan nasal sprays
• Entire IV insulin infusion administered at fluid rate

Volume 23, Issue 6

In this issue:

• Barcode Scanning Will Help Prevent Errors with Enteral Nutrition Feedings
• Prevent mix-ups between intravenous (IV) lipids and ViperSlide
• Magnesium infusion almost administered instead of heparin
• Vial coring and fragmentation pose risks

Volume 23, Issue 7

In this issue:

• what’s in a Name? The “-peridone” drug stem name
• Delay in emergency medication delivery caused by syringe design
• Never dilute a medication in a saline flush syringe
• Label design may result in incorrect dose

Volume 23, Issue 8

In this issue:

• Practitioners Need to Warn Patients About Purchasing Counterfeit Drugs Online
• Cap color led to close call with high-alert medications
• Remembering Dr. Lucian Leape

Volume 23, Issue 9

In this issue:

• what’s in a Name? The “-nal-” drug stem name
• Nilotinib formulations are NOT interchangeable
• Contaminated WG critical Care calcium gluconate 2,000 mg/100 mL bag
• Hazard! Broselow Rainbow Tape contains incorrect information

Volume 23, Issue 10

In this issue:

• Saline Infusions and Flush Syringes May Not Be as “Harmless” as You Think – Scanning Will Help
• Another Potentially Contaminated Calcium Gluconate Bag – Now by Amneal!
• Cresemba Unit-Dose Blisters Contain a Desiccant
• EPINEPHrine Auto-Injector Does Not Have a Retractable Needle
• RifAMPin and Rifapentine Mix-Ups

Volume 23, Issue 11

In this issue:

• What’s in a Name? The “-cycline” Drug Stem Name
• Two Health Technology Hazards That Put Patient Safety at Risk
• KIDs List Has Been Updated
• Worth Repeating…Methemoglobinemia Risk After Administration of Hurricaine Spray

Volume 23, Issue 12

In this issue: