ISMP has received reports from several healthcare institutions that recently received cardboard cases labeled “Isoflurane USP 100 mL” by Piramal Critical Care (NDC 66794-017-10) (Figure 1) that actually contained bottles of Isoflurane, USP 100 mL labeled “for animal use only” by Covetrus (NDC 11695
Medication Safety Alerts
In addition to a full suite of medication safety newsletters for healthcare professionals and consumers, ISMP makes available urgent medication advisories. These Safety Alerts address serious medication errors or information requiring immediate attention by healthcare practitioners.
ISMP Special Alerts
ISMP collects and analyzes thousands of medication error and adverse event reports each year, including through its voluntary ISMP National Medication Errors Reporting Program (ISMP MERP), National Vaccine Errors Reporting Program (ISMP VERP), and consumer medication error reporting program (ISMP C-MERP). ISMP issues alerts through its many communication channels to share emerging information on errors happening across the nation, “lessons learned,” and prevention strategies with the entire healthcare community.
NAN Alerts
Beginning in 2009, ISMP joined the American Society of Health-System Pharmacists (ASHP) and other members of the National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP) to create a National Alert Network (NAN). The NAN warns healthcare providers through several national distribution channels about actual or potential medication errors that have recently caused serious harm or death. The alerts are based on information submitted to the ISMP MERP.
On December 22, 2021, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for PAXLOVID, consisting of oral tablets of nirmatrelvir that are co-packaged with oral tablets of ritonavir (an FDA-approved antiretroviral agent). Indications Emergency use of Paxlovid is
ISMP has received reports from two different hospitals about McKesson packaged levetiracetam 250 unit dose blister packages that have a barcode that scans as naproxen 500 mg. Apparently one side of the unit dose blister of 10 levetiracetam tablets scans properly, but the barcode on other side
URGENT – HAZARDOUS SITUATION – PLEASE REACT IMMEDIATELY ISMP is aware of an extremely hazardous packaging error involving certain cisatracurium products from Meitheal Pharmaceuticals. While the outer carton identifies the vials inside as cisatracurium, the vials contained in the carton are labeled
If you are using NUCALA (mepolizumab) for patients who have eosinophilic asthma, please check to ensure the correct volume is being dispensed. Some healthcare practitioners have been confused by the vial labeling.
Imagine giving the opioid antagonist naloxone in error to someone with severe pain who is receiving morphine via patient controlled analgesia. That risk exists in hospitals that stock verapamil injection 5 mg per 2 mL vials manufactured by Exela Pharma Sciences and naloxone injection 0.4 mg per mL
Misleading acetaminophen liquid packaging could lead to acetaminophen overdoses. Caution is advised regarding labeling and packaging of acetaminophen liquid products now on store shelves at several leading chain pharmacies. CVS, Walgreen, Walmart and likely other chain pharmacies are currently
Almost 20 years ago, we published an article about SANDIMMUNE (cycloSPORINE capsules and oral solution) and how this non-modified form of the drug has decreased...
BRIDION (sugammadex), a neuromuscular blocking reversal agent, has a peel-off label that expresses the drug concentration in a different...
We learned of an incident last week involving an unopened DILAUDID (HYDROmorphone) prefilled syringe (SIMPLIST, Fresenius Kabi), which was brought into...
An emergency department (ED) pharmacist was talking to a patient about his U-500 insulin dose. The patient, who had been using a U-500 insulin pen, told the...
The recently revised label on propofol 200 mg/20 mL vials by Sagent Pharmaceuticals is likely to cause problems during barcode scanning now that the...
SMOFLIPID 20% lipid injectable emulsion from Fresenius Kabi (100 mL, 250 mL, and 500 mL) is a four-oil intravenous lipid emulsion for...