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July 1, 2010

  • DTaP-Tdap mix-ups now affecting hundreds of patients
  • Post-production IV admixture checks less than ideal

    ISMP is aware of two recent fatal errors that reached patients due to IV admixture errors that were not detected during the checking process.  For further discussion of the problematic processes associated with checking IV admixtures, along with recommendations for safe practice, check out this week’s issue.
  • Dyed but not dead: methylene blue overdose risk

    Discover why your organization may be at risk of administering an overdose of methylene blue and what you can do to prevent it from occurring.
  • Safety Brief: Caffeine and sodium benzoate injection.

    There has been dosing confusion tied to the label of a recently revised American Regent product of caffeine and sodium benzoate injection.  Learn how these dosing errors have occurred.
  • Safety Brief: Symbiq infusion system.

    Two weeks ago Hospira updated customers regarding an ongoing issue with its Symbiq Infusion System.  Read more at:
  • Safety Brief: Twice a week or twice a month?

    The words “biweekly” and “bimonthly” each have two different meanings.  Discover why the use of these words would likely cause confusion and could lead to error.
  • Safety Brief: Dangerous abbreviation “BIW.”

    Learn about an error that occurred due to the use of the abbreviation “BIW” and why the abbreviation “BIW” should never be used.
  • Safety Brief: Standard concentrations for neonatal drug infusions.

    ISMP and Vermont Oxford Network have been working together to draft a list of commonly used neonatal IV medications/solutions to help establish standard concentrations and dosing units. We have posted the recommendations on our Web site ( and invite you to send comments on the draft to by August 31, 2010.
  • Safety Brief: ISMP Canada launches consumer-oriented Web site.

    Congratulations to our sister organization, ISMP Canada, on the launch of their new Web site, The Web site provides a way for consumers in Canada to report medication incidents to ISMP Canada and also provides useful suggestions on steps consumers can take to reduce the chances of a medication mistake.

Special Announcements

  • Take our survey on tall man letters.

    ISMP is updating its current list of Look-Alike Drug Name Sets With Recommended Tall Man Letters ( This list was first compiled after a survey in 2008 to help healthcare organizations employ a standard set of tall man letters to differentiate look-alike drug names. We are considering a few more name pairs that have been involved in errors to add to this list and would like your opinion. ISMP’s list, containing both generic and brand names, is not an FDA-approved list, so use of tall man letters by the medical industry for package labels and medical devices still requires FDA approval unless the name already appears on the FDA-approved list ( The FDA list only contains generic drug names. Based in part on your response to our survey, ISMP will make recommendations to the FDA as appropriate regarding additional generic drug name pairs to be added to the agency’s list. Please help us learn more about tall man letters by taking our survey by July 30, 2010 at:  
  • ISMP Employment.

    Our growing medication safety consulting operation is seeking an experienced pharmacist or nurse (preferred PharmD, MSN, MS or in progress) for a fulltime position based at our Horsham, PA (near Philadelphia) office. For more information, go Send your curriculum vitae (CV) and a brief statement of interest to, subject header: Medication Safety Specialist.
  • ISMP July webinar.

    Back by popular demand, on July 22 we will present our annual The Joint Commission (TJC) Medication Management Update (2010). Our speaker, Darryl Rich, PharmD, a surveyor for TJC, will discuss new and revised medication standards for hospitals and insightful tips to help you meet the intent of the standards. For details, visit:
  • ISMP Cheers Awards!

    Nominations for this year’s ISMP Cheers Awards will be accepted through August 27, 2010. The prestigious Cheers Awards honor individuals, organizations, companies, and agencies that have set a superlative standard of excellence in the prevention of medication errors and other adverse drug events during the previous year. For more information or to submit a nomination, visit:

July 15, 2010

  • Preventing catheter/tubing misconnections: Much needed help is on the way
  • April-June 2010 ISMP Quarterly Action Agenda

    See the PDF version of the newsletter for the latest Action Agenda. For a Word version of the Action Agenda, which allows you to document your organization’s assessment and progress, please visit:
  • Safety Brief: Concentration change for Rugby iron sulfate drops.

    At least one generic manufacturer, Rugby Laboratories, has decided to change the concentration of its iron sulfate pediatric drops to 15 mg elemental iron per 1 mL from 15 mg/0.6 mL.  Check out this week’s issue to learn how this change in concentration may contribute to confusion and dosing errors.
  • Safety Brief: IV fat emulsion shortage update.

    The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) has participated in ongoing communication with US suppliers of IV fat emulsion (IVFE) about the current shortage.  For IVFE usage strategies during the shortage, please review A.S.P.E.N.’s recommendations (“Information to Use in the Event of an Intravenous Fat Emulsion Shortage”) at:  For additional information regarding the shortage, please see this week’s issue. 
  • Medication safety blog.

    ISMP president Michael Cohen contributes to a weekly guest blog on, the Web site operated by the Philadelphia Inquirer and Philadelphia Daily News. Be sure to read the blog regularly and add comments about your experiences to enhance the medication safety-related postings for healthcare consumers. The blog pages’ link is:
Special Announcements
  • Step Up Your Medication Safety Efforts with ISMP.

    Healthcare practitioners with medication safety oversight responsibilities have the opportunity to join ISMP experts for a 2-day interactive Medication Safety INTENSIVE workshop in Orlando, FL, on November 4 and 5. Participants will gain cutting-edge knowledge, tools, and strategies to establish an aggressive, focused medication safety program that is built on experience-based recommendations and strategies. For more details and to register, visit:

July 29, 2010

  • Drug shortages threaten patient safety
  • Safety Brief: LOVENOX unit-dose syringe alert.

    ISMP posted a Special Alert last week about the manufacturer’s label coming loose from certain Lovenox (enoxaparin) unit-dose syringes. For more information, please visit:
  • Safety Brief: Lidocaine “without” EPINEPHrine.

    An order for lidocaine 1% without EPINEPHrine was written using the medical symbol for “without” (lower case “s” with a line above). A picture illustrating how this order was written is available in our current issue. Find out how the use of this symbol could potentially result in misinterpretation.
  • Safety Brief: Air embolism risk with pressurized sprayers.

    The FDA has identified cases of air embolisms that appear to be related to the application of fibrin sealants using air- or gas-pressurized sprayers. Although rare, these reports describe air embolisms that were life threatening and include one fatality. More information can be found at:
  • Safety Brief: Sound-alike name pair #1

    A community pharmacist was transferring a prescription to another pharmacy by telephone. The verbal transmission sounded like the antidepressant PARoxetine, but the transferred prescription was for the nonsteroidal anti-inflammatory drug piroxicam.
  • Safety Brief: Sound-alike name pair #2

    ISMP recently received a report from a nurse describing a mix-up between FANAPT (iloperidone), a newly FDA-approved atypical antipsychotic agent for the acute treatment of patients with schizophrenia, and another medication.
  • Safety Brief: Acetaminophen study yields worrisome results

    The July/August issue of the Annals of Pharmacotherapy contains a study on prescription and nonprescription acetaminophen use among Medi-Cal patients during a 1 year period. Findings from the study showed that 769 consumers were potentially exposed to at least 16 g of acetaminophen for at least 1 day while 2,664 were potentially exposed to at least 4 g a day for at least 100 days.
Special Announcements
  • New Fellows. ISMP welcomes Rabih Dabliz, PharmD, the 2010-2011 ISMP Safe Medication Management Fellow. Rabih graduated from the ACPE-accredited Lebanese American University (LAU) School of Pharmacy. He completed a Pharmacy Practice Residency at St. Michael’s Medical Center in NJ, and a Pediatric Residency at Peyton Manning Children’s Hospital at St. Vincent in IN. Prior to joining ISMP, he served as a clinical assistant professor at LAU. Rabih’s fellowship is supported through a grant from the Cardinal Health Foundation. Also, ISMP and FDA welcome Samantha Cotter, PharmD, BCPS,the 2010-2011 FDA-ISMP Safe Medication Management Fellow. Samantha graduatedfrom the University of Rhode Island College of Pharmacy. She completed a Pharmacy Practice Residency at the University Medical Center of Southern Nevada in Las Vegas. Prior to joining ISMP, she served as the clinical pharmacist coordinator at Saints Medical Center in Lowell, MA. During this FDA-funded fellowship, Samantha will spend 6 months at ISMP followed by 6 months at the FDA Center for Drug Evaluation and Research, Division of Medication Error Prevention and Analysis.
  • ISMP Survey on Drug Shortages. Drug shortages have reached an all-time high, particularly with high-alert medications, and some healthcare practitioners have reported serious consequences related to the selection and use of alternative products or dosage strengths/forms. We want to hear about your experiences as well! Please take a few minutes to complete our survey on drug shortages. Please submit your responses to ISMP via by September 15, 2010. These results will support us to advocate for changes on a national level aimed at reducing the occurrence of drug shortages.

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