ISMP Medication Safety Alert!® Community/Ambulatory Care Newsletter - 2025 Single Issues

Volume 24, Issue 1

In this issue:

• Multiple NDCs for a single prescription fill leads to overdose
• Wrong-dose errors are possible with Trikafta packaging
• Worth repeating…Standardize the process to reconstitute oral products
• Look-alike Sandoz ophthalmic cartons
• Reconstitution error with SHINGRIX vaccine
• Potential to confuse KlonoPIN for cloZAPine
• Wrong delivery address for specialty pharmacy order
• Double trouble from Camber again –similar drug names and labels
• ISMP Medication Safety Alert! Action Agenda (September - December 2024)
  

Volume 24, Issue 2

In this issue:

• Targeted Medication Safety Best Practices for Community Pharmacy: Three new Best Practices
• Nilotinib formulations–Danziten and Tasigna–are not interchangeable
• Different strengths printed on cartons of temozolomide
• More prescription bags given to the wrong patients
• Patient readmitted to hospital after mix-up between bumetanide and budesonide
• MetFORMIN and methocarbamol bottles look alike

Volume 24, Issue 3

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Volume 24, Issue 4

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Volume 24, Issue 5

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Volume 24, Issue 6

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Volume 24, Issue 7

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Volume 24, Issue 8

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Volume 24, Issue 9

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Volume 24, Issue 10

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Volume 24, Issue 11

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Volume 24, Issue 12

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