The following are excerpts from the newsletter

October 20, 2011

  • FDA Advise-ERR: FDA approves HYDROmorphone labeling revisions to reduce medication errors
  • What’s wrong with “ketofol”? In a word, plenty!  The term “ketofol” is becoming commonplace in many hospitals. It’s a term used to describe a combination of ketamine (KETALAR) and propofol (DIPRIVAN). The admixture is used for procedural sedation.  While studies have shown that “ketofol” appears to be effective and safe for procedural sedation before painful procedures,a few important safety issues linger.
  • Safety Brief:  Trace elements conundrum. With the continued shortage of many injectable products, a hospital ran out of its usual pediatric trace elements injection (Trace Elements Injection 4, USP–Pediatric) in 10 mL multiple-dose vials from American Regent. As a substitute they ordered the company’s MULTITRACE-4 PEDIATRIC in 3 mL single-dose vials.  This product states on the label, “Trace Elements Injection 4, USP,” just like it states on the 10 mL vial. The pharmacists thought the only difference between this product and their usual pediatric trace elements solution was the smaller vial size and the fact that it was a single-dose vial.
  • Safety Brief:  PCN-200, not penicillin! A nutritional supplement called “PCN-200” may very well be among the options if someone types “PCN” into your computer system when entering patient allergies. PCN-200 was a grapefruit seed extract product that was discontinued by its manufacturer, Bio-Tech Pharmacal, several years ago. The problem is that it is still showing up when healthcare personnel attempt to enter a penicillin allergy in the computer system’s allergy field by typing “PCN.”
  • Take our survey on high-alert medications It’s been more than 3 years since welast updated ISMP’s List of High-Alert Medications. Please complete our short survey on page 4 and submit your findings by December 16, 2011 at: We would like to know whether YOU believe the medications listed in the survey belong on a high-alert medication list and whether YOUR PRACTICE SITE considers them to be high-alert medications with special precautions in place. We are also interested in your opinion regarding medications that should be added to ISMP’s list. The survey will take about 15 minutes to complete. We value your opinion and appreciate your time

Special Announcements...

  • ISMP symposium. Improper preparation of sterile IV products has led to patient deaths and gained increasing attention as a public health issue. If you would like to learn how barcoding, digital imaging technology, and improved staff training can reduce the risk of IV compounding errors, attend ISMP’s symposium at the ASHP Midyear Clinical Meeting on Tuesday, December 6. To register, visit:
  • Cheers registration. Join us for this year’s ISMP Cheers Awards reception and dinner as we honor our award winners and celebrate another year of superlative work advancing our shared goal of medication error prevention. This year’s gala will be held at the New Orleans Board of Trade on December 6, in conjunction with the ASHP Midyear Clinical Meeting. To register, please visit:
  • ISMP webinars. Join us as we hold our last two webinars of the year: 
    November 17—When Caring Hurts: Understanding the Second Victim Experience
    December 14—HYDROmorphone: Taking Aim at Events Under the Radar—Regional Initiatives that Show Improvement.
    For details on these ISMP webinars, visit:
  • IHI white paper updated. The Institute for Healthcare Improvement (IHI) has published an updated version of its white paper, Respectful Management of Serious Clinical Adverse Events. The white paper is available at: IHI’s approach draws on patient- and family-centered care, patient safety, and disaster planning to guide the management of events. The white paper is built upon the experiences of healthcare organizations that have attempted to manage such crises in a respectful and effective manner.
  • DVD sale. For a limited time, we are offering a series of medication safety DVDs marked down from $125 to $50. The four featured DVDs include: Medical Leaders in Patient Safety, Patient Safety Requires a Team Effort, Building System Safeguards for the Safe Use of High-Alert Medications, and Patients Play a Vital Role in Patient Safety. For details,visit:

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