• Propofol sedation: Who should administer?
• Near sight/sound dead hit!

  Confusion between OMACOR (omega-3-acid ethyl esters) and AMICAR (aminocaproic acid) leads to a dispensing error.

• Seeing (and hearing) double.

  Pressing a number key on Alaris SE pumps may result in an unintended repeat of that number, signaled by a double beep by the pump.

• Maalox brand name extension causes confusion.

  A new formulation of MAALOX (aluminum-magnesium hydroxide and simethicone) known as Maalox Total Stomach Relief looks identical to regular Maalox, but contains bismuth subsalicylate.

• Special announcements.

  ISMP announces the 8 th Annual Cheers Awards winners and Lifetime Achievement Award recipient.

• Mail service and community pharmacies must work in tandem
• Look-alike Tylenol packets.

  A packaging change for unit-dose TYLENOL (acetaminophen) 500 mg caplets makes the product virtually indistinguishable from Tylenol 325 mg packets.

• Label change number two.

  A change in the color of the label on Baxter’s phenytoin helped to differentiate heparin and phenytoin vials, but created a new look-alike situation.

• FDA-ISMP campaign.

  ISMP and FDA will create a comprehensive educational campaign aimed at eliminating error-prone abbreviations.

• Communication can avert harm from preventable ADRs.

  A communication failure among healthcare providers, and between healthcare providers and the patient leads to two preventable adverse drug reactions (ADRs).

• ISMP Activities at the ASHP Midyear Meeting.

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