The following are excerpts from the newsletter

May 3, 2012

  • Cheers honoree’s acceptance speech creates pause for reflection

  • Safety Brief:  Gimme “da heparin.” An interesting dispensing error happened when an order for the low molecular weight heparin product dalteparin was read as heparin. A physician wrote an order for dalteparin 15,000 units subcutaneously daily but the order was misinterpreted as heparin after it was faxed to a community pharmacy.

  • Safety Brief: Proper use of single-dose vials. The Centers for Disease Control and Prevention (CDC) recently restated a position statement, “Protect Patients Against Preventable Harm from Improper Use of Single-dose/Single use Vials” The position statement was created in response to ongoing questions and misinformation about CDC’s injection safety guidance, and ISMP has communicated its support.

  • Safety Brief: Do you know what drugs are present on your nursing units?  In a hospital that performs organ transplants, a 20,000 units/mL heparin vial was found in the hospital’s operating room (OR) even though the hospital never purchased or distributed such a product, after it was felt to be an unsafe and an unnecessary concentration to stock. After much investigation, it was found that an organ harvesting team had brought it into the medical center, intending to use it during the case.

  • NAN alert issued. The National Alert Network (NAN) was activated on April 25 to address proper disposal of transdermal fentaNYL systems (fentaNYL patches).

  • ISMP webinar. Join us on May 22 to hear firsthand about the release of ISMP’s guidelines for safe preparation of IV admixtures. This special webinar, Safe IV Compounding Procedures: The Release of ISMP Guidelines, will highlight best practice guidelines that were developed in response to a series of admixture tragedies involving IV compounding procedures. These guidelines are the result of an interdisciplinary safety summit held to perform an in-depth analysis of current compounding processes.

  • ISMP webinar.   Join us on June 14 for The Joint Commission Medication Management Update for 2012. Our speaker, Darryl Rich, will be reviewing The Joint Commission’s 2012 requirements associated with medication management standards and medication-related national patient safety goals, focusing on compliance issues found during surveys, new requirements, and current interpretations along with examples of best practices for meeting the requirements.              
    For details on both webinars, visit:

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