

ISMP Medication Safety Alert!® Community/Ambulatory Care Newsletter - 2022 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 21, Issue 1
In this issue:
- Start the Year Off Right by Addressing These Top 5 Medication Safety Concerns from 2021
- 2022 Ushers in the Beginning of a New Era at ISMP
- Worth repeating…Caution when restarting cloZAPine
- Error involving Paxlovid packaging
- Errors with injectable specialty medications
- ISMP Medication Safety Alert! Action Agenda (September - December 2021)
Volume 21, Issue 2
In this issue:
- It is Time for a Change: Respond to Consumers’ Error Concerns with Empathy and Honesty
- Look-alike cartons: Potential for wrong specialty product to be dispensed
- Worth repeating…Safeguards needed when copying an old prescription
- Azithromycin packaging confusion
- Do not dilute gray-capped Pfizer-BioNTech COVID-19 vaccine!
- Nonspecific PRN medication administration
Volume 21, Issue 3
In this issue:
- Disrespectful Behaviors and Their Negative Effects in Healthcare
- Advise patients to beware of desiccants in blister cards
- Cometriq selected instead of CoQ10
- CVS Caremark limits DOAC use
Volume 21, Issue 4
In this issue:
- Wrong Directions–mL Instead of mg–Provided on the Prescription Label of Pediatric Propranolol Oral Liquid
- Pharmacies should support and help patients navigate the path to access out-of-stock medications
- New ECRI and ISMP Headquarters
- Bar code scan to prevent errors with look-alike packaging
- Hidden pork content in COLACE capsules
- Similar names of oral contraceptives
- Reminder: Please take our brief survey on disrespectful behavior at your workplace
Volume 21, Issue 5
In this issue:
- Personal Practice Changes Practitioners Would Make after Learning Firsthand about Medication Errors at ISMP
- FDA Advise-ERR: Pen injectors need pen needles!
- Worth repeating...More patients have swallowed the desiccants in everolimus blister cards
- Poor fax quality leads to specialty pharmacy error
- Paxlovid drug interactions
- Eprontia oral solution concentration conversion
- ISMP Medication Safety Alert! Action Agenda (January- April 2022)
Volume 21, Issue 6
In this issue:
- Numerous Wrong Dose Errors with PAXLOVID
- Additional risk of age-related mix-ups now that our youngest patients are eligible for COVID-19 vaccines
- Common workaround contributes to override of barcode alert
- Different concentrations of oral liquid baclofen
- Mix-ups between fluticasone formulations
- Eprontia oral solution concentration conversion
- Nominations open for Cheers Awards
Volume 21, Issue 7
In this issue:
- Survey results: Practitioners Speak Up about the Persistence of Disrespectful Behaviors in Healthcare
- COVID-19 vaccine package concern
- Wrong dosing unit used in directions
- Pharmacists can prescribe PAXLOVID and need to be aware of error risks
Volume 21, Issue 8
In this issue:
- Workflow Vulnerability Leads to Missed Drug-Drug Interaction
- Take a tour of ISMP’s updated consumer website: ConsumerMedSafety.org
- Meet our three new 2022-2023 Fellows
- Look-alike Menactra and MenQuadfi packages
- Pfizer and FDA respond to Paxlovid error reports
- Risk of prescribing an overdose in athenahealth’s EHR
- Accidental needlestick with Evenity prefilled syringe
Volume 21, Issue 9
In this issue:
- ISMP National Vaccine Errors Reporting Program: 2020-2021 Analysis Focuses on Age-Related, Non-Covid-19 Vaccine Errors
- Bivalent and monovalent COVID-19 vaccine mix-ups
- Changes in dosing frequency not matched by dispensed amounts
- Patient drank albuterol nebulization solution
- Your Reports at Work: Important safety news for pets!
- ISMP Medication Safety Alert! Action Agenda (May - August 2022)
- ISMP 25th Annual Cheers Awards
Volume 21, Issue 10
In this issue:
- Drug Diversion—A Direct and Indirect Threat to Patient Safety
- Look-alike medication bottles from Zydus
- Confused drug names: ILARIS and ILUMYA
- Specialty refill reminder breakdowns
- Worth repeating…Mix-ups between coronavirus disease 2019 (COVID-19) and influenza (flu) vaccines
- Please take our survey on tall man letters!
Volume 21, Issue 11
In this issue:
- Addressing Disrespectful Behaviors and Creating a Respectful, Healthy Workplace
- Confusion among the many Humira products
- Look-alike QUEtiapine containers
- Expanded access to adult vaccines
- Your Reports at Work…New ready-to-use vaccine presentation does not require reconstitution
Volume 21, Issue 12
In this issue:
- Packaging Changes and Clinical Decision Support Needed to Help Prevent Mix-ups between Adult and Pediatric BIKTARVY Products
- Methotrexate taken daily after a wrong-drug error
- Your Reports at Work…ROTARIX reformulated but beware of the cap
- ISMP’s 25th Annual Cheers Awards: Walking the red carpet with safety stars
- Missing information on OTC liquid acetaminophen risks overdose
- Critical TRUVADA stability information not in package insert
- PDMPs can identify duplicate opioid therapy

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