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July 14, 2011

  • Too many abandon the “second victims” of medical errors
  • Safety Brief: Use vials as intended
    We recently received a report about vials of SENSORCAINE-MPF, complaining  about difficulty in gaining access to the vial’s rubber stopper for needle insertion, as well as risk of exposing the contents to the environment.
  • Safety Brief: Tall man letters in RxNorm
    As of July 5, 2011,the ISMP list of drug names using tall man letters ( is now incorporated in RxNorm.
  • Your reports at work: Tamiflu concentration change
    FDA and Genentech announced a change in the concentration of TAMIFLU suspension (oseltamivir phosphate) from 12 mg/mL to 6 mg/mL.

Special Announcements

  • ISMP webinars
    On August 17, ISMP will present The Joint Commission Update. Learn about the 2011 requirements for medication management standards and medicationrelated national patient safety goals. Darryl S. Rich, PharmD, a Joint Commission surveyor, will also discuss compliance issues found during past surveys and examples of best practices for meeting TJC requirements. For details, visit:
  • ISMP Medication Safety Alert! Acute Care (ISSN 1550-6312) ©2011 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP Medication Errors Reporting Program (MERP) at 1-800-FAIL-SAF(E). Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality of information received and respects reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Email:; Tel: 215-947-7797; Fax: 215-914-1492. This is a peer reviewed publication. 

July 28, 2011

  • Oral solid medication appearance should play a greater role in medication error prevention
  • Safety Brief: Nuclear medicine vials still don’t have barcodes
    We recently received a report from a commercial nuclear pharmacy about a “cold” (prior to activation) radiopharmaceutical vial of DraxImage DTPA (Technetium Tc 99m pentetate injection) being inadvertently placed in a leaded vial shield instead of DraxImage MDP-25 (Technetium Tc 99m medronate injection). The error resulted in obtaining nondiagnostic images with 12 patients. The lack of a manufacturer’s barcode with the product’s NDC number on radiopharmaceutical vials is a significant contributing factor with product selection errors in the nuclear pharmacy industry.
  • Safety Brief: An RxNorm fix for colistin
    There is a risk of serious or fatal medication errors associated with the ambiguity of dosage and concentration expressions of colistimethate sodium. In the US, the dosage and strength/concentration of colistimethate sodium are expressed in terms of colistin (the active form), NOT colistimethate (which is inactive). RxNorm has agreed that a change is warranted, which the company said will appear in the September RxNorm update.
  • Safety Brief: BD insulin syringe scales changing
    Although a small change, BD has announced that, in keeping with the latest healthcare guidelines, the company’s insulin syringe scales will soon include mL, the universal liquid measurement. Check out this week’s newsletter to learn more about how this change may cause confusion.
  • Worth Reading: Epidural analgesic spiked with IV tubing
    In a labor and delivery unit, the primary nurse started a patient’s IV, while another nurse helped to prepare the room and medications. Orders were written for both an antibiotic and epidural analgesia. The second nurse inadvertently spiked the bag containing the epidural analgesia instead of the antibiotic with a secondary IV tubing set, and leaving the incorrect bag on the IV pole for the primary nurse to administer. Fortunately, the error was discovered by the primary nurse before it reached the patient. You can read our latest newsletter to find out more about how errors like this one may be prevented in your practice setting.

Special Announcements

  • ISMP webinar. On August 17, ISMP will present The Joint Commission (TJC) Medication Management Update 2011. Learn about the 2011 medication-related standards and national patient safety goals. Darryl S. Rich, PharmD, a Joint Commission surveyor, will discuss compliance issues found during surveys and how to avoid them. For details, visit:

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