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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.

October 5, 2006

  • Harmful errors: How will your facility respond?
  • Growth in error reporting

    Organizational leaders need to make sure board members and staff understand the value of error reporting, which often includes potential hazards and risks that could lead to errors and errors that were caught before they reached the patient.

  • Improved plastic ampuls

    Two manufacturers of medications packaged in low density polyethylene plastic are improving the labeling of their containers.

  • ISMP Quarterly Action Agenda
  • The July-September 2006 ISMP Quarterly Action Agenda appears in the PDF version of the newsletter. Subscribers can also download a Word version of the Action Agenda  (, which allows expansion of the boxes designated for organizational documentation of an assessment, actions required, and assignments for each agenda item.

Special Announcements

  • November teleconferences

  • Join ISMP for our November 15th teleconference, Automated Dispensing Cabinets (ADCs): A Double Edged Sword That Can Either Enhance or Worsen Safety. 

October 19, 2006

  • "And the 'EYES' have it": Eardrops, that is...
  • Key bounce and keying errors

    The news media recently published several articles about an infusion pump programming error that left an 18-year-old woman with limited mobility of her legs. While the exact cause of the programming error is unclear, it's apparent that a keying or key bounce error may have occurred.
  • Unsafe marketing practice

    Allergan distributes over-the-counter LACRILUBE S.O.P eye ointment in a carton that contains a promotional package insert for the prescription drug, RESTASIS (cylcosporine ophthalmic).
  • No follow through with color

    The cartons that hold ALPHAGAN P (brimonidine tartrate) ophthalmic solutions use color and font size effectively as a way to differentiate the two available strengths, 0.1% and 0.15%. However, the enclosed dropper bottles themselves are not color differentiated, and the small font size used to show the concentration makes them look identical.
  • Another ADC stocking error

    We recently learned about another ADC stocking error that led to patient harm. A nurse removed a bag of dopamine from an ADC believing it contained the usual concentration of 1,600 mcg/mL. Instead, the bag contained 800 mcg/mL (400 mg/500 mL), which had been accidentally stocked in the ADC in an area where 250 mL bags of dopamine 400 mg/250 mL were usually stored.
  • Minibag’s tubing cap can occlude PCA flow

    PharMEDium, a specialty medication provider, seals the minibag tubing of epidural preparations with a blue plastic cap to prevent leakage.
    We have received a report from a hospital in which three patients receiving PCA, failed to receive any drug because nurses accidentally connected the pump tubing to the blue cap instead of removing it and connecting the administration set to the tubing on the minibag.

Special Announcements

  • Publication

    The second edition of the ISMP book, Medication Errors (first published in 1999), edited by Michael R. Cohen, is now available. In this expanded 600+ page edition, Dr. Cohen brings together some 30 experts from pharmacy, medicine, nursing, and risk management to provide the most current thinking about the causes of medication errors and strategies to prevent them. To place an order, please visit:

  • Recognition

    9th Annual ISMP Cheers Awards. Please join us on December 5, 2006, at the Hilton Anaheim in CA, as we honor the 9th Annual ISMP Cheers Awards recipients. Charles R. Denham, MD, Chairman of Texas Medical Institute of Technology, will deliver the keynote address, and ISMP staff will present the Awards. For more information, please visit:

  • Support

    Medication safety program for rural hospitals. Small hospitals often face challenges managing safety priorities on limited resources and have difficulty finding educational programs that address their unique concerns. To help support those needs, ISMP is launching the ISMP Rural Hospital Medication Safety Connection. The Connection provides tools and collaborative learning opportunities to help rural hospitals significantly improve medication safety. For more information, please visit:

  • Education

    ADC teleconference. Please join us for our next teleconference, Strategies for Safe Use of Automated Dispensing Cabinets (ADCs), on November 15, 2006, from 1:30 to 3:00 p.m. EST. This teleconference will identify the causes of errors related to ADCs and the components of a well-designed ADC system that can reduce the risk of errors. To register, visit:

    Medication reconciliation seminar. On October 27, 2006, in Dallas, ISMP and Joint Commission Resources (JCR) will present a 1-day seminar, Medication Reconciliation: An Organizational Approach to Improving Patient Safety Outcomes. The seminar will provide case studies of medication reconciliation in hospitals and facilitate discussion groups to apply the knowledge learned. For details, call 877-223-6866 or visit:

    Teleconference on package insert changes. ISMP and FDA will be holding a free teleconference, New Prescription Drug Information Format to Improve Patient Safety, on November 7, 2006, from 12:30 to 2 p.m. EST. FDA has revised the format of prescription drug information (package insert) to reduce the risk of errors and make the information more accessible for electronic use. To learn more, please contact: Attendance is limited to 200 locations

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