

ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2021 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 19, Issue 1
In this issue:
- Prevent Shoulder Injuries During Intramuscular COVID-19 Vaccinations
- what’s in a Name? The “-conazole” drug stem name
- Marvel’s newest Superheroes: NURSES
- Administer adenosine rapidly for cardioversion
- Expiration date or beyond-use date?
- Paralyzing agent vial caps without warnings into 2022
- Obtain 1 hour of FREE nursing CE
- ISMP Fellowship: Applications now being accepted through March 31, 2021
Volume 19, Issue 2
In this issue:
- Learning from Errors with the New Coronavirus Disease 2019 (COVID-19) Vaccines
- USP coronavirus disease 2019 (COVID-19) vaccine toolkit
- The first five letters are not always enough
- Error-prone concentrations of ibuprofen suspensions
- Calling All Nurse Faculty!
Volume 19, Issue 3
In this issue:
- The Differences Between Human Error, At-Risk Behavior, and Reckless Behavior are Key to a Just Culture
- what’s in a Name? The “-fentanil” drug stem name
- Dispense unit dose syringes using the most appropriate concentration
- Silicone-free syringes required
- National Poison Prevention Week – March 21-27, 2021
Volume 19, Issue 4
In this issue:
- A Recurring Call to Action: Every healthcare Organization Needs a Medication Safety Officer!
- SIRVA (shoulder injury related to vaccine administration) persists
- Vaccine card incorrect for single-dose coronavirus disease 2019 (COVID-19) vaccine
- Nurses Month – May 2021
Volume 19, Issue 5
In this issue:
- Analysis of Transdermal Medication Patch Errors Uncovers a “Patchwork” of Safety Challenges
- what’s in a Name? The “-ciclib” drug stem name
- One more reason to require scanning of flushes
- Two patients receive EPINEPHrine instead of coronavirus disease 2019 (COVID-19) vaccine
- Problem with Guangdong Haiou syringes for coronavirus disease 2019 (COVID-19) vaccinations
- Launch of ISMP perioperative medication safety self assessment!
Volume 19, Issue 6
In this issue:
- Just Culture, Medication Error Prevention, and Second Victim Support Essential in Nursing Curriculum
- Maximizing automated dispensing cabinets (ADC) medication removal and restocking accuracy
- Misconnections between cecostomy and gastrostomy
- Barcode scanning indicates wrong drug
- Proper way to open MicroVault cover
- ASPEN Fact Sheet about parenteral nutrition (PN) in-line filters
Volume 19, Issue 7
In this issue:
- Administration of Concentrated Potassium Chloride for Injection During a Code: Still Deadly!
- what’s in a Name? The “-parib” drug stem name
- Do not use Dr. Reddy’s prefilled glass naloxone syringes with a MicroClave connector
- Preferred vs. legal name of transgender patients
- Obtain 1 hour of Continuing Education (CE) – FREE!
- ISMP Medication Safety Self Assessment for Perioperative Settings – Submission Deadline Extended to October 1, 2021!
Volume 19, Issue 8
In this issue:
- Tennessee Board of Nursing’s Unjust Decision to Revoke Nurse’s License: Travesty on Top of Tragedy!
- “What happens if you give potassium chloride IV push?”
- Inadvertent intra-arterial promethazine injury
Volume 19, Issue 9
In this issue:
- Infection Transmission Risk with Shared Glucometers, Fingerstick Devices, and Insulin Pens
- How will PCA (patient controlled analgesia) be administered to patients during an MRI (magnetic resonance imaging)?
- great catch: PRAXBIND label information needs repositioning
- what’s in a Name? The “-begron” drug stem name
- Risks with leaving discontinued infusions connected to the patient
Volume 19, Issue 10
In this issue:
- Disrespectful Behavior in Healthcare: Has It Improved?
- In loving memory of Hedy Cohen
- Zantac reborn
- Confusing labeling on a two-dose blister
- Self assessment (perioperative) deadline extended to December 10, 2021!
Volume 19, Issue 11
In this issue:
- Safety Communities Need to Proactively Address the Risk of Accidental Cerebral Injection of Intravenous (IV) Drugs
- FDA communicates on the accuracy of ENFit low dose tip syringes
- TRULICITY pen should never be primed
- Drug manufacturers: Stop printing barcodes across round surfaces!
- Meet our 2021-2022 Fellows:
- ISMP 24th Annual Cheers Awards virtual celebration – December 7, 2021
Volume 19, Issue 12
In this issue:
- Multiple Error Pathways with the Monoclonal Antibodies, Casirivimab and Imdevimab
- what’s in a Name? The “-pemem” stem name
- Age-related coronavirus disease 2019 (COVID-19) vaccine mix-ups
- Safe use of parenteral nutrition
- Labeling of transdermal scopolamine products

ISMP Medication Safety Alert!® Nurse AdviseERR Newsletter - 2021 Single Issues
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