The following are excerpts from the newsletter

October 6, 2011

  • QuarterWatch 2010 (Quarter 4 and annual summary)
    Signals for two newly approved drugs: dabigatran and dalfampridine
  • Safety Brief: Differentiating penicillin from penicillAMINE. An electronic prescription for penicillamine (CUPRIMINE) was ordered for a 9-year-old patient who tested positive for Streptococcus. The nurse practitioner meant to order penicillin, not the chelating agent. The error was not caught until the patient had taken the medication for 2 days and was not improving. Tall man lettering was added to penicillAMINE in the ordering database.
  • Safety Brief: Infusion reconnected to the wrong patient. Both patients in a semi-private room had been disconnected from their primary IV solutions so they could take showers. Each patient’s primary solution hung on separate mobile IV poles but were right next to each other between the two beds. Afterwards, a nurse went to start a piggyback antibiotic for one of the patients, but realized she had not restarted the patient’s primary infusion. After reconnecting the primary infusion, the nurse attached the piggyback antibiotic solution to a port in the primary infusion tubing. She then realized she had connected the wrong primary line to the patient.
  •  Safety Brief: Spell out acetaminophen on prescription labels.  Prescription container labels often list ‘‘APAP’’ as an abbreviation for the drug name. Yet most patients do not realize this means their medication contains acetaminophen. To reduce the potential for confusion, the National Council for Prescription Drug Programs (NCPDP) has published a white paper, “NCPDP Recommendations for Improved Prescription Container Labels for Medicines Containing Acetaminophen,” detailing recommendations to improve prescription labeling practices. The paper can be accessed at:
    Special Announcements:
    • Participate in oncology survey: The Hematology/Oncology Pharmacy Association (HOPA) has released a survey to characterize oncology drug shortages, including chemotherapy, supportive care, and other agents used for cancer care across the US. The survey is best completed by a small team, such as an oncology pharmacist, oncology nurse, purchasing staff, and others routinely involved in managing drug shortages. Please complete only one survey per institution (not per individual hospital-based infusion site) by October 28, 2011. You can access the survey at:
    • ISMP Cheers Awards will be presented at a dinner reception Tuesday evening, December 6, 2011, from 6:00 to 9:30 p.m. at the New Orleans Board of Trade, 316 Board of Trade Place, New Orleans, Louisiana. To register, please visit:

    ISMP webinars:

    • On October 27, ISMP will present Pediatric Medication Safety: The Physician’s and Pharmacist’s Perspectives. An environment of collaboration and teamwork between the pediatrician and the pediatric pharmacist is a critical component of a reliable medication system. This webinar will discuss the physician-pharmacist interface along with other essential topics such as teamwork, disruptive behavior, and disclosure as key elements in supporting safe practice in this specialty population.
    • On November 17, ISMP will present When Caring Hurts: Understanding the Second Victim Experience. When patients suffer unexpected clinical events, healthcare clinicians are also at risk of suffering as a result of the unanticipated outcome and become "second victims." Suffering practitioners feel as though they have failed the patient and frequently second guess their clinical skills, knowledge base, and career choice. Join Susan Scott, MSN, a patient safety officer who has conducted studies on this topic, as she describes the second victim experience and interventional strategies, including use of a specialized rapid-response team.
    • On December 14, ISMP will present HYDROmorphone: Taking Aim at Events Under the Radar - Regional Initiatives that Show Improvement. HYDROmorphone continues to be associated with patient harm. Some organizations have begun to recognize this risk, while others may not be aware of the number of adverse events associated with this drug. Join us to learn how to uncover these "hidden" events and to hear about safety strategies that several hospitals are implementing to prevent HYDROmorphone-related events.
      For details, visit:

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