News Release

ISMP Alerts Healthcare Practitioners about Medication Errors and Hazards Related to COVID-19

The Institute for Safe Medication Practices (ISMP) special edition of the ISMP Medication Safety Alert!® acute care newsletter this week provides details on reports of emerging medication-related events and risks due to the COVID-19 pandemic. The issue highlights a hospital compounding error due in part to confusion over the labeling of remdesivir as an investigational drug, which led to overdoses in patients.

ISMP also provides an alert that a double concentration (2%) of propofol has been approved for marketing in the US to address pending shortages, which may lead to overdoses if healthcare practitioners are not aware that the concentration is higher than what is currently available.

In addition, this special edition includes insight and tips on:

  • Impact of COVID-19 staffing changes, including failure to engage BCMA

  • Inability to weigh patients during telehealth encounters

  • Missing doses, especially with albuterol inhalers, for COVID-19 patients

  • “VL” search in automated dispensing cabinet that led to verapamil instead of Versed

  • Mix-up between compounded hydroxychloroquine and hydrochlorothiazide oral suspension

The special edition newsletters are being made available for free to the general public as well as subscribers. To access a copy, click here. Please note that access may require free registration.

COVID-19 Resource Center

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Since the 2021-2022 influenza (flu) vaccine became available in September, the Institute for Safe Medication Practices (ISMP) has received multiple reports of mix-ups. Some patients have consented to a flu vaccine but received one of the COVID-19 vaccines instead, while others have received the flue