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August 12, 2010

  • Generic enoxaparin syringe issue
  • Affirmative warnings (do this) may be better understood than negative warnings (do not do that)
  • Limit niMODipine liquid preparation only to the pharmacy

    FDA reminded healthcare professionals last week that niMODipine capsules should be given only by mouth or through a feeding tube. Since some patients are incapable of swallowing capsules, the drug often needs to be given via a feeding tube as a liquid dosage form. Check out this week’s issue for recommendations on how to prepare and safely label the extemporaneous preparation. 
  • Safety Brief: Generic enoxaparin syringe issue

    In our last issue we wrote about a problem with the manufacturer’s label coming loose on certain LOVENOX (enoxaparin) unit-dose syringes (30 mg and 40 mg). This week, Sandoz, which recently released generic enoxaparin, confirmed a different problem. Learn more about this problem and what your institution can do about it.
  • Safety Brief: VistaPharm Xactdose labels to be revised

    We have received a number of reports about the labeling of Xactdose unit dose liquid containers from VistaPharm, Inc., of Birmingham, AL who recently changed the way the drug concentrations are expressed on their labels. Find out how this label change can result in a 25% overdose of phenytoin.
  • Safety Brief: Drug shortage survey

    Don’t miss an opportunity to let your voice be heard about problems that drug shortages create for patients and staff, as well as yourself. Please participate in our survey on drug shortages at: Responses from over 1,000 respondents so far show that substantial resources are being devoted to investigating shortages, correcting ordering problems, and finding alternatives to suggest to prescribers.

  • Safety Brief: Why shortages occur

    In case you missed it, there is an excellent article by FDA’s Valerie Jensen and Bob Rappaport that details how drug shortages occur. The article uses propofol as a case study and clears up a good deal of misinformation that we have been hearing. Find out how you can access this article.

Special Announcements

  • ISMP Cheers Awards! Nominations for this year’s ISMP Cheers Awards will be accepted through August 27, 2010. The prestigious Cheers Awards honor individuals, organizations, companies, and agencies that have set a superlative standard of excellence in the prevention of medication errors during the previous year. For more information or to submit a nomination, visit:

  • Step up your safety efforts with ISMP. Health-care practitioners with medication safety oversight responsibilities have an opportunity to join ISMP experts for a 2-day interactive Medication Safety INTENSIVE workshop in Orlando, FL, on November 4-5. Participants will gain cutting-edge knowledge, tools, and strategies to establish a focused medication safety program built on experience-based strategies. For details and to register, visit:

  • ISMP webinar. On September 28, ISMP will present Beyond ‘Be Careful’: Maximizing Peri-natal Medication Safety, to help practitioners working in OB settings reduce risks associated with the administration of high-alert drugs such as oxytocin, magnesium sulfate, and narcotics. Experts will present high-leverage system safeguards for the perinatal setting and also address the challenges of caring for pregnant patients in EDs and ICUs. For information, visit:

  • Human factors engineering (HFE)workshop. ISMP safety partners, John Gosbee, MD, and Laura Lin Gosbee, MASc, will be holding a Human Factors Engineering & Medical Device Workshop in Ann Arbor, MI, on October 21-22. During design exercises, participants will practice HFE methods (usability testing) that will help improve the design of existing and new products. For details, visit:

August 26, 2010

  • Electronic prescribing vulnerabilities: Height and weight mix-up leads to dosing error
  • Safety Brief: Odor neutralizer won’t protect skin

    A concern has been identified about a potential for mix-ups between a spray barrier film and a commonly used odor neutralizer. The two products are commonly used in hospitals and long-term care facilities and could potentially be in a patient’s room at the same time. Both products are available in similar size spray bottles and, therefore, look and appear very similar, although product label colors are slightly different. Check out this week’s issue to find out about which products were involved in the mix-up.
  • Safety Brief: Look-alike vials

    An OR pharmacist reported to ISMP a potential for a mix-up between two injections that are commonly stored together in the OR medication cart. Find out more about the similarity between these two products.
  • Safety Brief: Update to Hospira Symbiq recall

    Hospira has confirmed the root cause of the Symbiq infusion pump’s failure to detect air in the line (ISMP Medication Safety Alert! Safety briefs. May 6, 2010). Hospira will be replacing its microbore administration sets. In the meantime, the company issued an advisory recommending what current users can do to prevent this problem.
  • Safety Brief: Sanofi aventis letter

    At the request of sanofi aventis, and as a public service, ISMP has agreed to provide a link to a letter from them regarding recent reports of label adherence issues with LOVENOX (enoxaparin) 30 mg and 40 mg prefilled unit dose syringes. The letter provides additional information about avoiding needlesticks when using the syringe and can be accessed through our newsletter.
  • Null sign misread

    In prior issues of our newsletters, we discussed the possible misidentification of alphanumeric symbols in handwritten and computer-generated information. A nurse who read this recommendation in the June issue of Nurse Advise-ERR told us about a medication error that happened in her hospital that was caused in large part by a misinterpreted null sign. To learn more about this incident and to view ISMP’s recommendations, check out our current issue of the newsletter.
  • Your reports at work

    Improved warnings coming for Clear Care
    Ciba Vision, the company that makes Clear Care Cleaning and Disinfecting Solution for contact lenses, informed us this week that they have been in communication with FDA regarding updates to the container warning system for their product. Our June 3, 2010, issue mentioned hundreds of incidents where contact lens wearers used the product improperly after missing warnings about soaking their lenses only in the special Clear Care contact lens holder packaged with the product. The company told us that they have been working on a new package design that would require the attachment of the contact lens holder to the bottle in order to use the solution. We hope that such a package will be available in the near future.

Special announcements

  • ISMP webinar. Join us on September 28 for our next webinar, Beyond ‘Be Careful’: Maximizing Perinatal Medication Safety, which will focus on reducing risks in OB and ED settings. For information, visit:


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