NAN Alert Archive

The National Alert Network (NAN) publishes the alerts from the National Medication Errors Reporting Program. NAN encourages the sharing and reporting of medication errors, so that lessons learned can be used to increase the safety of the medication use system.
Jul 10, 2024 Manufacturer’s dexmedeTOMIDine premixed IV bags may be packaged within an overwrap labeled as acetaminophen
May 17, 2022 Potassium chloride for injection concentrate in EXCEL plastic bags
Dec 06, 2021 Age-related COVID-19 vaccine mix-ups
Oct 15, 2021 Mix-ups between the influenza (flu) vaccine and COVID-19 vaccines
Sep 09, 2020 Dangerous Wrong-Route Errors with Tranexamic Acid
May 24, 2018 Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages
Oct 12, 2017 Severe hyperglycemia in patients incorrectly using insulin pens at home
Sep 15, 2016 Observe for possible fluid leakage when preparing parenteral syringes
Jun 30, 2015 Move toward full use of metric dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL.
Mar 23, 2015 Bloxiverz and Vazculep potential for mix-ups
Feb 18, 2014 Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation
Jun 10, 2013 Important Change with Heparin Labels
Apr 17, 2013 Confusion regarding the generic name of the HER2-targeted drug KADCYLA (ado-trastuzumab emtansine)
Jan 23, 2013 Severe burns and permanent scarring after glacial acetic acid (≥ 99.5%) mistakenly applied topically
Apr 25, 2012 Proper disposal of fentaNYL patches is critical to prevent accidental exposure
Mar 18, 2012 Potential for wrong route errors with Exparel (bupivacaine liposome injectable suspension)
Jun 29, 2011 Risk of potentially fatal overdose with colistimethate
Jun 01, 2010 EPINEPHrine pre-filled syringe shortage
Apr 08, 2010 Another child is victim of heparin error
Aug 13, 2009 Errors lead to fatal hyponatremia in two healthy children
Apr 10, 2008 Deaths from overdose of fosphenytoin
Mar 27, 2008 Cross-contamination in insulin pens