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Back issues of the newsletter to January 1996 are available on CD-ROM.

September 7, 2006

  • Diastat Acudial: Dial, set, and lock the dose
  • Since the introduction of this product, a number of errors have occurred because the product syringe was not dialed, set, and locked to the prescribed dose by the pharmacy.

  • Not really that complex
  • Similarity in the nonproprietary names of two factor IX products, BEBULIN VH (Factor IX Complex, Vapor Heated) and BENEFIX [Coagulation factor IX (recombinant)], pose threat of mix-ups.

  • Why the abbreviation “PCN” should be avoided
  • Two recently reported medication errors involving the use of the abbreviation “PCN” demonstrate why it should be avoided.

  • Mucomyst may be prescribed long term
  • Long-term indications for MUCOMYST (acetylcysteine) intensify mix-up potential with MUCINEX (guaifenesin).

Special Announcements…

  • ISMP survey on promethazine

    ISMP is asking for your help in defining the scope of the problem and prioritizing strategies to avoid severe tissue damage when administering IV promethazine. Please complete the survey even if you no longer use promethazine in your facility. Submit responses to ISMP by September 29th, via the internet ( or fax (215–914–1492).
  • September teleconferences

    Join ISMP for our September 13th teleconference, Improving Medication Safety with Antithrombotic Agents.  The speakers will discuss safety practices for various classes of antithrombotic agents, including the use of inpatient and outpatient antithrombotic teams or services, antithrombotic protocols, patient monitoring, and preprinted order sets.
  • Free FDA Patient Safety Videos

    The latest medication-related videos are available on the ISMP Web site ( and may be viewed or downloaded.
  • Medication reconciliation seminars

    Joint Commission Resources and ISMP will be presenting a 1-day seminar, Medication Reconciliation: An Organizational Approach to Improving Patient Safety Outcomes, on September 26 in Alexandria, VA, and on October 27 in Dallas, TX. Learn powerful strategies for building or refining your medication reconciliation process through actual case studies. For details, call 877-223-6866 or visit

September 21, 2006

  • Our long journey towards a safety-minded Just Culture; Part II: Where we're going
  • Medication reconciliation and community pharmacy
  • Pharmacists who work in community and mail-order pharmacies may be unaware of the reconciliation process used in hospitals and, thus, may be uneasy or resistant to sharing information about a patient’s current medications.

  • Infant heparin flush overdose

    The news media recently reported that three premature infants died at a Midwestern hospital after receiving an overdose of heparin last weekend.

  • Prefilled adenosine syringe incompatible with CLAVE needleless system

    We were surprised to receive a report this week that Baxter’s prefilled syringes of adenosine are incompatible with the CLAVE intravenous system needleless connectors.

  • Drug name alerts

    We recently became aware of two potential drug mix-up names pairs: AZILECT (rasagiline) and ARICEPT (donepezil), and NEULASTA (pegfilgrastim) and LUNESTA (eszopiclone).

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