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The following are excerpts from the newsletter

  • Success with New Year's resolutions requiresmore than personal resolve
  • ISMP Quarterly Action Agenda: October - December 2002
  • A point about levothyroxine - Physician confusion about decimal point placement with levothyroxine doses is a commonly reported problem.
  • Safety Briefs
    • Our New Look! - The ISMP Medication Safety Alert! is now available in a new Adobe Acrobat (PDF document) format. We hope the new design will improve readability and increase the publication's value in communicating important patient safety information. Click here for subscription information. Comments and suggestions are invited and can be directed to using our contact form.
    • ISMP has published reports about errors with the reconstitution of HERCEPTIN (trastuzumab).
    • Baxter's 10 mL atracurium besylate injection vials have excellent labeling, but the lavender colors on the labels and the gray snap-off caps are patterned similarly to Bedford's 10 mL ketorolac injection.

January 23, 2003

  • Water, water, everywhere, but please don't give IV
  • Don't confuse varicella virus vaccine with varicella-zoster immune globulin - Mix-ups with Varivax (varicella virus vaccine) and VZIG (varicella-zoster immune globulin) have been reported due to confusion between their similar names or lack of understanding of the appropriate indications for use.
  • Safety Briefs
    • Intra-arterial lines can unwittingly furnish a route of administration for medications intended for IV administration.
    • Using a parenteral syringe for an oral medication and allowing a parent to administer a medication to a hospitalized infant led to a near disaster!
    • Florida appellate court ruling stated that parents have a duty to ask physicians about medications prescribed for their children, and to check pharmacy information sheets provided with the medication in order to verify that the correct medication has been dispensed
    • Make sure staff are aware that peanut allergy is a contraindication for Atrovent Inhalation Aerosol, and also for COMBIVENT Inhalation Aerosol (ipratropium and albuterol.
    • Join ISMP in celebrating National Patient Safety Awareness Week from March 9-15, 2003, by participating in a contest about involving patients in medication safety initiatives! Contest entries should answer one of the following questions:

      1) How have you involved the community at large in medication safety awareness?

      2) How have you involved inpatients in medication safety initiatives while under your direct care?

      3) How have you involved outpatients in medication safety initiatives while under your direct care?

      To enter the contest, submit a description of your efforts along with supporting materials (required). Examples of supporting materials include press releases, editorials, public service announcements, patient brochures, policies and procedures, meeting minutes, business plans, educational calendars, and survey findings. Entries should be e-mailed (, faxed (215-914-1492) or mailed to ISMP. Entries must be received by February 21, 2003, and should include your name, organization, address, and phone number. One winner in each of the three categories will receive a new videotape on high alert drugs and $250 for your organization. We will post the winning examples (with permission) on our web site. For more information on National Patient Safety Awareness Week, visit the National Patient Safety Foundation web site at

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