The following are excerpts from the newsletter

May 17, 2012

  • Just Culture and its critical link to patient safety (Part I)

  • Safety Brief:  Disposal of fentaNYL patches in hospitals. We received several email messages after our May 3 newsletter regarding an alert we issued about a child’s death after placing an improperly disposed fentanyl patch in his mouth. Product labeling specifies the drug should be disposed of by flushing it down the toilet. However, FDA stated that the issue of hospital disposal in a secured sharps container was not discussed for inclusion in product labeling. Additionally, FDA’s advice addresses individual patient disposal in the home, not institutional disposal.

  • Safety Brief:  Arixtra—not a hemostat.  A hospital pharmacist got quite a scare when he reviewed a surgeon’s discharge note that said, in part, “There was some bleeding in the pelvis that had been irrigated, and Arixtra was placed in the pelvis for homeostasis.”  FDA approved Arista AH as a device after the drug Arixtra had been approved. Seems the brand name similarity was not recognized when Arista AH was approved.

  • Safety Brief:  Drug shortage bills in Congress.  Last week the House Energy and Commerce Committee unanimously approved legislation to reauthorize the Prescription Drug User Fee Act to help alleviate critical drug shortages.

  • Safety Brief:  Pradaxa-Plavix mix-up.  A physician reported an error that happened to a 99-year-old man with paroxysmal atrial fibrillation and a recent arterial embolism. He wrote a prescription for PRADAXA (dabigatran etexilate) that was mistakenly dispensed as PLAVIX (clopidogrel).

  • Special Announcements:  ISMP nurses recognized for safety work.  ISMP congratulates Judy Smetzer, BSN, RN, FISMP, and Susan Paparella, MSN, RN, each a vice president at ISMP.  On May 2 at the unSUMMIT for Bedside Barcoding in Anaheim, CA, Judy was recognized with the 2012 Way-Paver For BPOC Award for her work in advancing bedside bar-coding at the point of care (BPOC). On April 14, Susan Paparella was awarded the Villanova University College of Nursing Medallion, the College’s highest award for “Distinguished Contributions to Clinical Practice.” The College noted that she has demonstrated continued leadership in patient safety on a national and global stage.

  •  ISMP welcomes Fellow from Saudi Arabia. Mohammed Aseeri, BS, PharmD, BCPS, recently joined ISMP as one of the 2012-2013 ISMP Safe Medication Management Fellows. 

  • ISMP Cheers Awards!  Nominations for this year’s ISMP Cheers Awards are now being accepted through September 14. The Cheers Awards honor individuals, organizations, companies, and agencies that have set a superlative standard of excellence in the prevention of medication errors during the previous year. For details, please visit:

  • 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. He will be focusing on compliance issues found during surveys, new requirements, and current interpretations along with examples of best practices for meeting the requirements. For details, visit:

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