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August 11, 2011

  • Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment
  • Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.
    Several errors involving misadministration of IV insulin were reported to us. The errors may be attributed to knowledge deficits regarding insulin concentrations, incorrect dose measurement, administration using parenteral syringes rather than insulin syringes and the perceived urgency with treating hyperkalemia. Find out more about these events and preventative strategies in this newsletter.
  • A step backward for patient safety? PhRMA seeks repeal of federal regulation that supports safety testing of drug names.
    There have been numerous mix-ups between products with confusing or similar names. The FDA’s name testing program allows for a proactive review of potentially error prone drug names. Find out more about the safety benefits of FDA’s program and why it should not be repealed. 
  • SafetyBriefs: Use of two pumps allow bypass of drug library.
    We were recently made aware of an event where Propofol was infused using two smart pumps as a workaround to a hard stop in the smart pump library.  Read more about this event in this issue.
  • Parenteral Nutrition Safety Survey.
    The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) needs data on how you are ordering, compounding, and labeling parenteral nutrition (PN). A.S.P.E.N. will use these findings to develop recommendations and PN safety guidelines at its September 23, 2011, PN Safety Summit, at which ISMP will participate. This survey is open to all clinicians involved with PN. The survey should take about 15 minutes and will close August 29, 2011. To take the survey, please visit:
  • Deadline extended to September 30, 2011 for the ISMP Medication Safety Self-Assessment for Hospitals.
    For a link to this project, please visit:

Special Announcement...

  • ISMP webinar. On September 28, ISMP will present HYDROmorphone: Taking Aim at Events Under the Radar—Regional Initiatives that Show Improvement. For details, visit:


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