

ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2020 Single Issues
The ISMP Medication Safety Alert!® Nurse AdviseERR is a digital newsletter for nurses who transcribe orders, administer medications, and monitor the effect of medications on patients.
Volume 18, Issue 1
In this issue:
- A Lot Happens When You Report a Hazard or Error to ISMP – There’s No “Black Hole” Here!
- Abbreviations to avoid
- ADC vendors to provide important new safety enhancement
- Shiny foil causes reading and scanning difficulty
Volume 18, Issue 2
In this issue:
- Errors Associated with Oxytocin Use: A Multi-Organization Analysis by ISMP and ISMP Canada
- what’s in a Name? The “-afil” drug name stem
- Now available from ISMP: Expanded Smart Pump Guidelines
- Confusion over antiretroviral therapy abbreviation
- Patient Safety Awareness Week: March 8-14-2020
Volume 18, Issue 3
In this issue:
- Special Edition: COVID-19
- Revisiting the Need for MDI Common Canister Protocols During the COVID-19 Pandemic
- Limit Use and Protect Supplies of Unproven but Widely Prescribed COVID-19 Treatment
- COVID-19 Collaboration
- Worth visiting…
Volume 18, Issue 4
In this issue:
- Clinical Experiences Keeping Infusion Pumps Outside the Room for COVID-19 Patients
- ECRI: Considerations for using infusion pumps outside of patient rooms
- COVID-19 Collaboration
- Gravity flow rate drip chart (B.Braun)
Volume 18, Issue 5
In this issue:
- Leadership Support is Vital: If We Fail to Support Caregivers, There will be Few Left to Support Care
- Trends with COVID-19-related medication errors
- Not all superheroes wear capes: National Nurses Week – May 6-12, 2020
- ADC usage during COVID-19
- COVID-19 Collaboration
Volume 18, Issue 6
In this issue:
- COVID-19-Related Medication Errors
- Nymalize formulation and packaging change
- Methadone overdose linked to scanning the wrong barcode
- Should the PillCrusher syringe be used for crushing tablets?
- Legacy feeding tubes, administration sets, and transition adapters going away
- Tragic errors involving fentaNYL nasal spray
Volume 18, Issue 7
In this issue:
- Education is “Predictably Disappointing” and Should Never be Relied Upon Alone to Improve Safety
- Special Alert! Watch for vials of neuromuscular blocking agents without caps warnings and double-concentration propofol
- FDA removes syringe administration from vinCRIStine labeling
- The KIDs List
- what’s in a Name? The “-capone” drug stem name
- ISMP now accepting nominations for CHEERS AWARDS
Volume 18, Issue 8
In this issue:
- NRFit: A Global “Fit” for Neuraxial Medication Safety
- ISMP survey on mixing injectable medications and infusions
- Confusion with VENCLEXTA unit dose package label continues
- Barcode scan workaround leads to error
- World Patient Safety Day: September 17, 2020
Volume 18, Issue 9
In this issue:
- During the Pandemic, Aspire to Identify and Prevent Medication Errors and to Avoid Blaming Attitudes
- what’s in a Name? The “-racetam” drug name stem
- ISMP survey on mixing injectable medications and infusions
- Label improvement for MYXREDLIN
- Lidocaine cardiac dose given instead of analgesic dose
- BD will not market an ISO 80369-3 compliant enteral syringe
- GEDSA members delay phase out of legacy enteral systems
- Nursing care for LGBTQ+ patients
- ECRI and ISMP to create a new joint PSO
Volume 18, Issue 10
In this issue:
- Subtherapeutic Heparin Infusions: Is Your Organization at Risk of Bypassing Soft Low-Dose Alerts?
- what’s in a Name? The “calci” drug name stem
- Properly engage the orange needle protection device
- That’s 15, not 50
- Name confusion with rapid-acting insulins
Volume 18, Issue 11
In this issue:
- ISMP Survey Provides Insights into Preparation and Admixture Practices OUTSIDE the Pharmacy
- Helping patients avoid insulin pen mix-ups
- Area to tear open patch wrapper can destroy the barcode
- Can a product have two different expiration dates?
- Ready to use but not ready to administer
- ISMP 23rd Annual Cheers Awards virtual event – December 8, 2020
Volume 18, Issue 12
In this issue:
- Need for Standardizing Critical Care Drug Infusions Has Never Been Greater
- Easy for Things to Go Wrong with Test Patients
- what’s in a Name? The “-xaban” drug stem name
- FentaNYL patch duration of drug delivery confused as patch strength
- Mix-up between droperidol and dronabinol
- New ASPEN recommendations for in-line filters for parenteral nutrition (PN)
- Good catch! Eye drop frequency error
- WAKIX and LASIX name confusion

ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2020 Single Issues
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