

ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2023 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 21, Issue 1
In this issue:
- Safety Considerations for Challenges When Using Smart Infusion Pumps
- Prefilled glass syringes incompatible with certain needlefree connectors
- QuVa Pharma two-sided labels for intravenous (IV) bags
- Avoid tearing the metal flange on the monkeypox (mpox) vaccine vial
- Paralytic cap warning is easily missed
- Expanded access to adult vaccines
- Become an ISMP Fellow
Volume 21, Issue 2
In this issue:
- ISMP Updates Its List of Drug names with Tall Man (Mixed Case) Letters Based on Survey Results
- what’s in a Name? The “-domide” stem name
- Worth repeating… Naloxone syringe and Clave/MicroClave connector incompatibility
- New ready-to-use vaccine is better, but may pose new hazard
- Inappropriate use of automated dispensing cabinet (ADC) overrides
- Become an ISMP Fellow
Volume 21, Issue 3
In this issue:
- Pump Up the Volume: How to Prioritize Events and Analyze Error Data
- Misprinted label on sodium chloride bag
- Follow VIVITROL preparation instructions to minimize clogged syringes
- HYDROmorphone administered via the wrong route
Volume 21, Issue 4
In this issue:
- Implement Strategies to Prevent Persistent Medication Errors and Hazards
- BD Alaris Pump shut off and did not infuse vasopressors
- Worth repeating… Never prepare oral or topical medications in a parenteral syringe!
- Join us in celebrating Nurses Month – May 2023!
Volume 21, Issue 5
In this issue:
- Controlled Substance Drug Diversion by Healthcare Workers as a Threat to Patient Safety – Part I
- what’s in a Name? The “-tecan” drug stem name
- Smudged intravenous (IV) bag label and a proxy scan set up a patient for a cardiac arrest
- Join us in celebrating Nurses Month – May 2023!
Volume 21, Issue 6
In this issue:
- Controlled Substance Drug Diversion by Healthcare Workers as a Threat to Patient Safety – Part II
- Death from air embolism after pneumatic tubing was connected to intravenous (IV) line
- SUMAtriptan injection – it’s subcutaneous only!
- ISMP Foundations in Medication Safety: Acute Care
Volume 21, Issue 7
In this issue:
- Patients are at Risk During Transitions of Care
- what’s in a Name? The “-oxetine” drug stem name
- Be aware of error-prone abbreviations
- Fewer high-alert drugs prescribed by dentists
- Obtain 1 hour of FREE nursing CE
Volume 21, Issue 8
In this issue:
- Smart Infusion Pump Investigations After an Unexplained Over-infusion
- Safety mechanism needed for EVENITY syringe needle to prevent needlestick injuries!
- Judy Smetzer Just Culture Champion Scholarships – applications now being accepted!
Volume 21, Issue 9
In this issue:
- Taking a Closer Look at Medication Errors Involving Intravenous Oxytocin
- The myth about the safety of the “Five Rights”
- Automated dispensing cabinet (ADC) drug description leads to mannitol overdose
- Worth repeating… Errors continue with B. Braun intravenous (IV) bag labeling and difficult-to-scan barcode
- what’s in a Name? The “-steride” drug stem name
- World Patient Safety Day – September 17
- Judy Smetzer Just Culture Champion Scholarships – applications now being accepted!
Volume 21, Issue 10
In this issue:
- Implement Strategies to Prevent Administration of Ear Drops into the Eyes
- what’s in a Name? The “cef-/ceph-“ drug stem name
- Confusing FLUZONE high-dose packaging leads to error
- Foiled again: “Major Rugby” barcode scanning issues
- Worth repeating… Education in proper use of insulin pen needles is needed
Volume 21, Issue 11
In this issue:
- Latent and Active Failures Perfectly Align to Allow a Preventable Adverse Event to Reach a Patient
- Broken tamper-evident oral syringe cap
- RYANODEX demo carton and vial look too much like the real thing
- ISMP 26th Annual Cheers Awards
Volume 21, Issue 12
In this issue:
- Intravenous (IV) Push Medications – Bridging the Gap Between Education and Clinical Practice
- what’s in a Name? The “-dronate” drug stem name
- Moderna coronavirus disease 2019 (COVID-19) vaccine overfill leads to a double dose
- Hazard Alert! Medisca 20 mL oral syringes could lead to dosing errors

ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2023 Single Issues
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