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The following are excerpts from the newsletter

March 9, 2006

A ‘code bug’ with Abacus™ TPN Calculation Software used with Baxa Compounder generates an error on the TPN compounding sheet.

  • Can’t touch this!

    A pregnant nurse unknowingly split at tablet of TRACLEER (bosentan) for a pediatric patient, and then learned the drug is a pregnancy category X.

  • Confusion over meaning of color-coded wristbands.

    The Pennsylvania Patient Safety Authority recently published an assessment of the risk associated with the use of color-coded patient wristbands, and an error reported to ISMP highlights these findings

March 23, 2006

A dispensing error occurred when a number and decimal point are cut off from the dosage on a prescription during scanning.

  • Color consistency.

The omission of a colorful sticker from an IV bag contributed to a mix-up between two products.

  • End it with Endrate.

The CDC recently alerted practitioners about fatal errors due to confusion between two chelating agents with look- and sound-alike names.

  • Acetaminophen toxicity:  more risk exposure than we thought?

A pharmacist reports to ISMP on an alarming trend she noticed: pharmacy labels for prescription drugs containing acetaminophen do not make it obvious that they contain acetaminophen or how much.

  • Valuable report on reporting values.

Communication of a critical lab value to a non-licensed worker was not reported directly to medical or nursing staff, and allowed a life-threatening situation to escalate for 36 hours.

Special Announcements…

  • ISMP Board Chair.

Louis Martinelli, PharmD, PhD is the new Chair of ISMP Board of Trustees.

  • Patient Safety Congress.

ISMP will cosponsor a meeting, Leadership for Safety: The Time is Now, at the Eighth Annual Patient Safety Congress in San Francisco, CA.  Visit for details and to register.

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