The following are excerpts from the newsletter

August 23, 2012

  • Avoiding inadvertent IV injection of oral liquids
  • Generic methylergonovine and Engerix-B mix-ups due to look-alike vials
  • Safety Brief: Insulin pen misuse by patient. A report was received about patient misusing a NovoLOG FlexPen (insulin aspart).  The patient suffered an overdose and arrived at a hospital emergency department due to a misunderstanding of how to read the insulin pen device.
  • Safety Brief: Diluent vial looks like drug vial. Mylan’s melphalan for injection is at a risk for errors.  This medication is packaged with a sterile diluent however both vials are the same size and both have white caps.  Each has identical coloring and backgrounds on the label.  We’ve notified Mylan about the risk of the diluent being given in place of the reconstituted medication.
  • Safety Brief: ON-Q pump with bupivacaine attached to IV. ISMP received a report about a patient who pulled out the ON-Q pump tubing from a wound area and attached it to his IV.  The ON-Q product labeling notes that the device is not intended for intravenous delivery.
  • ISMP webinar. On September 28, ISMP will present Addressing Opioid Safety Risks in Hospitals. 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:

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