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The full version of the newsletter is available by subscription
Back issues of the newsletter to January 1996 are available on CD-ROM.


July 3, 2008

  • Epidural-IV route mix-ups: Reducing the risk of deadly errors
  • Safety Brief: Use ShrinkSafe safely.

    A pharmacist recently reported that he found a vial of succinylcholine in an automated dispensing cabinet bin that was supposed to hold vecuronium vials. Both products were enclosed in SHRINKSAFE ID Bands which may have contributed to the mix-up.

  • Safety Brief: Discontinued drug leads to error.
  • A discontinued minibag of diltiazem was returned to pharmacy for recycling where it was erroneously relabeled ZOSYN (piperacillin and tazobactam) and dispensed to another patient. A series of fortunate catches prevented a serious, possibly fatal, medication error. Review processes for returning and relabeling medications to prevent a similar mishap in your organization.
  • Your Reports at Work!  Dose countdown.

    Astra Zeneca, maker of PULMICORT FLEXHALER (budesonide inhalation powder), received approval for an update to the “patient’s instructions for use” section of the product label in order to provide more accurate information about how the device displays remaining doses.  Read how a clinician’s concern led to this change.

Special Announcements

  • ISMP teleconference.

    Join us for our next teleconference, The Joint Commission (TJC) Update: 2008-2009 Requirements Related to Medication Use, to be held on July 23 and repeated on August 21. For details, please visit: www.ismp.org/educational/teleconferences.asp
  • Harvard Colloquium.

    The Seventh Quality Colloquium is scheduled to be held August 18-21, 2008, on the campus of Harvard University in Cambridge, MA. The Quality Colloquium—ISMP is one of the program sponsors—will address the issues of patient safety, healthcare reliability, teams and team training, medical education, and medical error reduction. For more information, please visit: www.QualityColloquium.com.

July 17, 2008

  • Heparin errors continue despite prior, high-profile, fatal events.
  • Quarterly Action Agenda April- June 2008.
  • Safety Brief: “C-IV” mistaken as “IV.”
  • A nurse working in radiology almost administered chloral hydrate syrup by the IV route when she confused the Roman numeral IV in the Drug Enforcement Agency (DEA) class four controlled substance symbol (C-IV) as “intravenous.” Read how to prevent similar errors in your institution.

  • Safety Brief: No concentration on label.

    Some heparin shipments from APP Pharmaceuticals (formerly Abraxis) are arriving in shipping cartons with labels that do not list the concentration. Read what you should do if you receive this type of shipping carton.

Special Announcements

  • ISMP teleconference.

    Join us for our next teleconference, The Joint Commission (TJC) Update: 2008-2009 Requirements Related to Medication Use, to be held on July 23 and repeated on August 21. For details, please visit: www.ismp.org/educational/teleconferences.asp

  • Harvard Colloquium.

    The Seventh Quality Colloquium is scheduled to be held August 18-21, 2008, on the campus of Harvard University in Cambridge, MA. The Quality Colloquium—ISMP is one of the program sponsors—will address the issues of patient safety, healthcare reliability, teams and team training, medical education, and medical error reduction. For more information, please visit: www.QualityColloquium.com.

July 31, 2008

  • Use of tall man letters is gaining wide acceptance
  • In the News…Fatal medication errors in the home

    Fatal Medication Error (FME) rates showed a 360.5% increase between January 1983 and December 2004 (Phillips DP, et al. A steep increase in domestic fatal medication errors with use of alcohol and/or street drugs. Arch Int Med2008;168:1561-6). Learn what health care professionals can do to help consumers reduce risk in their homes.
  • Safety Brief: Ambulatory e-Rx requires patient’s check.

    E-prescribing is becoming more prevalent. We were told about a recent experience at a physician’s office. The doctor sent the order for a medication directly to the pharmacy, but the doctor never told the family exactly WHAT drug he was prescribing. They were just instructed to pick up the medication at their community pharmacy. Read what your practice can do to ensure patient safety with new technology.

Special Announcements
  • Harvard Colloquium.

    The Seventh Quality Colloquium is scheduled to be held August 18-21, 2008, on the campus of Harvard University in Cambridge, MA. The Quality Colloquium—ISMP is one of the program sponsors—will address the issues of patient safety, healthcare reliability, teams and team training, medical education, and medical error reduction. For more information, please visit: www.QualityColloquium.com.
  • Maximize the effectiveness of your medication safety team!

    ISMP will hold a two-part teleconference series to help healthcare organizations meet the challenges involved with creating and maintaining a successful medication safety team, including establishing a joint accountability model, determining the role of a physician leader, and using data and external information to effect change. This dynamic two-part teleconference series will be offered on September 17, 2008 and October 23, 2008 at 1:30 pm (ET). For details, visit: www.ismp.org/educational/teleconferences.asp.

  • Take our survey.

    ISMP is conducting a survey on smart infusion pumps. If you use smart pumps, please have the individual most knowledgeable about current use of the pumps complete the survey located at: www.ismp.org/survey/Survey200806.asp by September 5, 2008.

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