The following are excerpts from the newsletter

July 12, 2012

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

  • Safety Brief:  Methadone dispensed for methylphenidate. A community pharmacy inadvertently dispensed methadone to a 7-year-old boy who normally takes methylphenidate 10 mg BID. The boy’s mother gave the medication as prescribed and the child became lethargic and vomited after taking one dose. ISMP and FDA have received multiple reports of confusion between methadone and methylphenidate.

  • Safety Brief: Too many numbers. A hospice prescription for "fentanyl transdermal 72h apply 1 patch 12 mcg/hour externally q3d" was incorrectly dispensed in several increments over 60 days as transdermal fentaNYL 75 mcg per hour. The error occurred because the initial drug order unnecessarily contained "72h" which refers to the standard release time of 3 days for all transdermal fentaNYL products.

  • Darryl Rich joins ISMP staff. ISMP is happy to announce that Darryl Rich, PharmD, MBA, has joined its consulting staff. Darryl has more than 30 years of experience in safe medication management that he will use to bring ISMP’s system-based philosophy to healthcare organizations. For more information on ISMP’s consulting services, visit:

  • Extended deadlines.  Participation in the 2012 ISMP International Medication Safety Self- Assessment for Oncology has been extended to September 30, 2012. Visit to register, download the assessment tool, and enter your findings.

  • ISMP is still accepting comments on its Sterile Preparation Compounding Safety Summit Proceedings until July 31, 2012 (


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