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The following are excerpts from the newsletter

December 13, 2007

  • Celebrating 10 years of ISMP CHEERS awards
  • Safety Briefs: Error could still happen.
  • A variety of system problems contributed to mix-ups involving  10 units/mL heparin and 10,000 units/mL heparin products manufactured by Baxter. Read this brief to learn which factors often contribute to mix-ups and how to assess and decrease risks associated with heparin and other high alert drugs in your organization.

  • Persistence saves patient’s life.
  • A pharmacist prevented significant patient harm by questioning an atypical methotrexate dose and persisting until his concerns were evaluated by other members of the healthcare team, including the patient’s family. This Safety Brief details other factors that contributed to this serious near-miss.  

  • Avoiding mix-ups between sterile water and sodium chloride bags.  
  • Take proactive steps to prevent the inadvertent administration of sterile water instead of sodium chloride by heeding lessons learned in organizations where these often tragic errors have occurred.

Special Announcements…
  • Draft ADC guidelines.

    A draft of the first set of consensus-driven safe practices for automated dispensing cabinets is now available. Please comment on the proposed guidelines for ADCs at: Comments will be accepted until December 31, 2007

  • ISMP teleconference.

    Please join us for our first 2008 teleconference, Safe Use of ADCs: Choosing Safety Over Convenience, to be held on January 30 from 1:30-3:00 p.m. ET. Speakers will address common errors associated with the use of automated dispensing cabinets (ADCs) and present new consensus recommendations designed to improve formulary management, drawer configuration, restocking procedures, system overrides, and medication withdrawal and transport. To register, visit:
  • Medication safety program for rural hospitals.

    ISMP offers a toolkit to help rural hospitals address unique challenges to medication safety that occur in small facilities.  For details, visit,

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