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The following are excerpts from the newsletter

january 12, 2006

FDA published a Public Health Advisory to warn US citizens about risks when obtaining drugs from foreign sources.

  • Labeling change.
Sanofi-pasteur received FDA approval for packaging and labeling changes on some of their vaccine products that aim to reduce mix-ups.
  • Unsafe abbreviation.

A medical abbreviation, SID, is sometimes used by veterinarians and has occasionally been misinterpreted.

A conflict arises with a practitioner unknowingly orders an unsafe dose of an IV medication when converting a patient over from oral therapy, and insists a nurse administer the medication as ordered.

  • It’s our 10 th anniversary.

As we begin our 11 th year publishing the ISMP Medication Safety Alert!®, the staff at ISMP would like to thank healthcare providers for making a commitment to medication safety and for implementing error-prevention strategies to reduce the risk of errors.

Special Announcements…

  • 2006 teleconference.

Our next teleconference, Preventing Errors with Insulin: An Interdisciplinary Approach , will be held on February 9, from 1:30 to 3:00 pm (ET). Visit to register.

  • New recommendations.

ASHP’s section of Inpatient Care Practitioners and the Hospital and Health System Association of Pennsylvania have recently published Professional Practice Recommendations for Safe Use of Insulin in Hospitals ( ).

  • ISMP Safe Medication Management Fellowship for 2006 -2007.

ISMP is now accepting applications for the 12- month program. Please visit for more information.


january 26, 2006

  • Tylenol packaging returns to yellow.

    McNeil’s pouches of 500mg Extra Strength TYLENOL (acetaminophen) returns will be returning to the familiar yellow color within the next 6 to 8 weeks.

  • On the watch.

    Confusion between a news sleep aid, ROZEREM (ramelteon), and RAZADYNE (galantamine) has been reported to ISMP by community pharmacists..

  • USP focuses on radiological procedures in 6 th annual MEDMARX report.

    According to USP, 12% of errors involving radiological procedures between 2000-2004 resulted in harm.

  • New Quarterly Action Agenda

    The ISMP Quarterly Action Agenda summarizes important topics published in the newsletter during the previous 3 months and will now present topics in a “to do” list format. Free continuing education credit is available for pharmacists and nurses.

Special Announcements…

  • HIMSS conference

    ISMP will be co-sponsering the 2006 HIMSS Annual Conference and Exhibition in San Diego from February 12-16, 2006. Visit for more information.

  • Antithrombotic self-assessment

    Pleas remember to submit your results from the ISMP Medication Safety Self Assessment® for Antithrombotic Therapy for Hospitals by March 1, 2006. Click here or contact Matt Fricker, RPh, at for more information.

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