

ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2024 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 22, Issue 1
In this issue:
- Ensuring Competency and Safety When Onboarding Newly Hired Professional Staff – Part I
- Worth repeating… Overwrap prevents barcode scanning
- what’s in a Name? The “-vastatin” drug stem name
- FDA warns of serious reaction to anti-seizure medications
- Confusion over sterility of povidone-iodine solution
- Obtain 1 hour of FREE nursing CE
Volume 22, Issue 2
In this issue:
- The Role of Simulation When Onboarding Healthcare Professionals – Part II
- ISMP List of High-Alert Medications recently updated
- Process for using Merck’s new prefilled diluent syringe is error prone
- Influenza vaccine mistaken as diluent meant for respiratory syncytial virus (RSV) vaccine
Volume 22, Issue 3
In this issue:
- Microlearning – Bringing Bite-Sized Heparin Education to Nursing Units
- Safe drug administration during fasting
- what’s in a Name? The “curium/-curonium” stem name
- No, not three lidocaine patches at a time!
- Join us in celebrating…Patient Safety Awareness Week, March 10-16, 2024
Volume 22, Issue 4
In this issue:
- Patient Death Tied to Lack of Proper Escalation Process for Barcode Scanning Failures
- Your Reports at Work: FDA requires updates to promethazine labeling
- Accidental overdoses and adverse effects from compounded GLP-1 agonists
- Incomplete verbal order leads to wrong dose
Volume 22, Issue 5
In this issue:
- Minimizing Distractions and Interruptions During Medication Safety Tasks
- How fast is too fast for IV push medications?
- what’s in a Name? The “-gepant” drug stem name
- Top 10 patient safety concerns for 2024
- Be a Nurse Leader at ISMP!
- Join us in celebrating Nurses Week May 6-12, 2024
Volume 22, Issue 6
In this issue:
- Recent Look-Alike Errors with MYXREDLIN Put Patients at Risk
- Sharing a good catch prevented a future error
- Kentucky law prevents practitioners from being criminally charged for medical errors
- Share your safety stories with us
Volume 22, Issue 7
In this issue:
- Patient Death After Inadvertent Infusion of PRN Medication Hanging on Bedside Intravenous (IV) Pole
- Demo product found in a code cart tray
- Delay finding calcium chloride syringe due to yellow color association
- Spike separating from the port of WG Critical Care infusion bags
Volume 22, Issue 8
In this issue:
- Drug Diversion Prevention Beyond Controlled Substance Medications
- Sidebar: Is your organization’s medication surveillance system positioned to detect foul play?
- what’s in a Name? The “-tadine” drug stem name
- Worth repeating…
Volume 22, Issue 9
In this issue:
- The Dark Side – Safety Issues When Protecting Medications from Light
- what’s in a Name? The “-caine” drug stem name
- Warning! Manufacturer’s dexmedeTOMIDine premixed intravenous (IV) bags may be packaged in an overwrap labeled as acetaminophen!
- Magnesium sulfate almost administered instead of dexmedeTOMIDine
- Dialysis bags may rupture during mixing
Volume 22, Issue 10
In this issue:
- Total Systems Safety Supports Practitioners in Partnering with Families to Protect Patients
- what’s in a Name? The “-ac” drug stem name
- Do not confuse these respiratory syncytial virus (RSV) products
- Only PRIORIX diluent was administered
- Vaccine registry not checked before administration
Volume 22, Issue 11
In this issue:
- Patients with Low Health Literacy Make More Errors Interpreting Instructions and Warnings
- Some products continue to present risks of needlestick injuries
- Hurricane Helene intravenous (IV) fluid update
Volume 22, Issue 12
In this issue:
- Implementation of Smart Infusion Pump Interoperability in the Emergency Department (ED)
- Fleet enemas, not as benign as they seem
- Insulin dosing error close call due to look-alike syringe packaging
- New medical device for hypertension calls for risk-prone 1 liter sterile water for injection bags
- Two phenazopyridine tablets packaged in a single unit dose blister
- Welcome to our newest staff members

ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2024 Single Issues
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