The following are excerpts from the newsletter

September 6, 2012

  • Prescription drug time guarantees and their impact   on patient safety in community pharmacies

  • Safety Brief: Color change for BD oral syringe tips. A pharmacist recently raised a safety concern regarding BD (Becton Dickinson and Company) oral syringes. The syringes used to have clear tip caps that were visible when placed upon an amber light-protective oral syringe. However, BD recently replaced the clear caps with amber colored caps that are the same color as the amber syringe, making it more difficult to see them while affixed to the syringe tip.

  • Safety Brief: Full content cannot be withdrawn from Istodax vial. Several oncology centers have told us about a frustrating issue related to the packaging of ISTODAX (romiDEPsin), a Celgene product indicated for cutaneous or peripheral T-cell lymphoma patients.

  • Safety Brief: Transdermal fentaNYL patient education checklist. ISMP received a report of an unresponsive patient who was brought to a hospital emergency department by his family. In the ED, staff immediately identified multiple patches of fentaNYL on his body. It appeared that patient misinterpreted the label instructions of “Apply one patch every 72 hours.” But there were no instructions on the label to remove the older patch when each new patch was applied.

  • Safety Brief: SA designation confusing. A pharmacist recently brought to our attention an expectorant liquid from Silarx Pharmaceuticals called SILTUSSIN SA (guaifenesin). From the name, one might deduce that Siltussin SA must be a special long-acting (sustained action) form of this cough medicine. However, that is not the case. SA, indicates the product is sugar- and alcohol-free.

  • ISMP oncology assessment. The deadline to complete and submit hospital findings for the 2012 ISMP International Medication Safety Self-Assessment for Oncology is Sept 30th. To access the tool, visit:

  • 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:

  • ISMP welcomes three fellows

    Annie Yang, PharmD, joins ISMP as the 2012-2013 ISMP Safe Medication Management Fellow/Stephen R. Lewis, MD, Fellow, supported by CareFusion Foundation.

     Ali-Reza Shah-Mohammadi, PharmD, MS, joins ISMP as the 2012-2013 ISMP Safe Medication Management Fellow, supported by Medco Foundation. 

    Tingting Gao, PharmD, joins ISMP as the 2012-2013 FDA/ISMP Safe Medication Management Fellow.

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