ISMP Medication Safety Alert!®

Featured Articles

The articles listed below were featured as the main topic in the ISMP Medication Safety Alert! Acute Care newsletter. Every two weeks a new article will be published highlighting important medication safety information. Related articles can be found in the full bi-weekly newsletter publication. You can access the full newsletter by going to the Publications and Alerts section of the website and searching by date for the corresponding newsletter issue.

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CRYSVITA (burosumab-twza) injection, approved by the US Food and Drug Administration (FDA) in April 2018, is a fibroblast growth factor 23 (FGF23) blocking antibody used to treat X-linked hypophosphatemia (XLH) in patients 6 months and older. XLH is caused by excess FGF23, which suppresses renal tubular phosphate reabsorption and renal production of 1,25-dihydroxyvitamin D. Before Crysvita, treatment with oral phosphates and active vitamin D was the standard of care for XLH.

Crysvita is contraindicated with concomitant use of oral phosphates and/or active vitamin D analogs (Table 1)...

Last week, ISMP celebrated our 22nd Annual Cheers Awards, which recognize organizations, groups, and individuals who have demonstrated an extraordinary commitment to advancing patient safety. This year’s winners were honored at a dinner held at Stoney’s Rockin’ Country in Las Vegas, NV, on December 10, 2019. Please join us in congratulating this impressive group of leaders who have played their cards well to create innovative projects, programs, educational efforts, and research to prevent medication errors and improve the safety of patient care. 

CHEERS Awards Winners

For more than 28...

ISMP is nearing the end of its 25th anniversary as the nation’s only nonprofit organization devoted entirely to medication error prevention. As we reflect on our accomplishments over the years, we recognize that you, too, have been pivotal to our successes because you have reported medication hazards and errors to us, bringing attention to significant medication safety issues. Every report is indispensable to us, and we want to assure you that the reports you submit never fall into a “black hole,” irretrievably lost and never to be seen again. To demonstrate this, we want to share with you all...

Healthcare practitioners are expected to speak up about patient safety concerns to help intercept errors and avoid adverse patient outcomes. By ‘speaking up,’ we mean raising concerns for the benefit of patient safety and quality of care upon recognizing or becoming aware of a risk or a potential risk.1 Such risks may include concerns about the safety of an order or treatment modality, a possible missed diagnosis, questionable clinical judgment, rule breaking, dangerous shortcuts, incompetence, and disrespect. Healthcare practitioners, especially frontline staff, are well positioned to observe...

In the July 16, 2019, issue of Pharmacy Practice News, ISMP president, Michael R. Cohen, published a noteworthy commentary about what healthcare consumers can do to help prevent medication errors.1 The inspiration for the commentary arose from significant dialog and questions received in response to articles ISMP published in this newsletter in early 2019.2-5 These articles were about a fatal error in which a woman received the paralyzing agent vecuronium, retrieved from an automated dispensing cabinet (ADC), instead of the sedative VERSED (discontinued brand of midazolam) (see Sidebar).

In...