The following are excerpts from the newsletter

November 1, 2012

  • Moving forward for safer sterile compounding
  • Safety Brief: FDA wants to hear from you. Investigations continue by the US Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention in light of the recent tragedies involving products from a compounding pharmacy.  The FDA stands ready to assist in addressing FDA-related issues associated with this outbreak.
  • Safety Brief: Another mL-teaspoonful mix-up. While preparing a dose of 2 mg (1 mL) of midazolam syrup (VERSED) for a child, a nurse had inadvertently measured a dose of 1 teaspoonful instead of 1 mL.  Upon further inspection, the BD oral syringe had both teaspoonful and mL scales.
  • Safety Brief: Designated Medication Manager. PULSE of New York has come up with a drug safety concept similar to that of having a designated driver for those that have consumed too much alcohol.  The program helps to minimize substance abuse for various medications.
  • Message in our mailbox. A message received by the Director of Accreditation and Medication Safety for Cardinal Health’s Pharmacy solutions applauds ISMP’s concerns in light of the tragedies involving medications from compounding pharmacies.  Further recommendations of entities that should establish a standard related to this pharmacy practice were discussed.
  • ISMP webinar. On December 18, ISMP will present their last webinar for the year titled Improving Medication Safety Through Staff Education and Competency Assessment: An Important Challenge for Healthcare Organizations. For details, please visit:


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