The following are excerpts from the newsletter

July 26, 2012

  • Raising the index of suspicion: Red flags that represent credible threats to patient safety

  • Worth Repeating: Confusion between EpiPen training device and active pen. A report was received about an emergency department automated dispensing cabinet (ADC) being stocked with an EPIPEN (EPINEPHrine injection) training device instead of the active EPINEPHrine 0.3 mg auto-injectors for anaphylaxis.  The manufacturer, Mylan, was again contacted about the packaging of the training device and active pens.

  • Safety Brief: Protocol needed for drug concentration change. A hospital reported that during preparation of a chemotherapeutic agent, a pharmacy technician noticed the concentration of DOCEtaxel in stock had changed.  The computer system did not have the new concentration of DOCEtaxel in its inventory.

  • Safety Brief: How much insulin is in a 3 mL vial? ISMP received a medication error involving Eli Lilly’s insulin 100 units/mL, 3 mL vials.  A nurse preparing an insulin drip read the U-100 (100 units per mL designation) as 100 units per vial.  Communication has been initiated with Lilly and the US Food and Drug Administration (FDA).

  • ISMP webinar. On August 16, ISMP will present Exploring Medication Safety Off the Beaten Path: Unique Medication Safety Challenges in Diagnostic and Procedural Areas. For details, please visit:

  • ISMP Cheers Awards. Nominations for this year’s ISMP Cheers Awards are now being accepted through September 14.  For details, please visit:

Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas
  - Free Nursing CEs
Special Alerts
Group Purchasing Subscription
Newsletter Editions
Acute Care
Community/Ambulatory Care
Nurse AdviseERR
Long-Term Care AdviseERR
Safe Medicine
Home | Contact UsEmployment  |   Legal Notices | Privacy Policy | Help Support ISMP
 Med-ERRS | Medication Safety Officer Society Medication Safety Officers Society | Consumer Medication Safety For consumers
ISMP Canada | ISMP Spain  | ISMP Brasil  | International Group  | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved