The following are excerpts from the newsletter

December 13, 2012

  • The 15th Annual ISMP Cheers Awards: Meet this year’s true gems in medication safety

  • Safety Brief:  Important change with heparin labels.  The US Food and Drug Administration (FDA) announced last week that, effective May 1, 2013, heparin vial labels must express the strength per the entire container followed by the strength per mL in parentheses. In the past, the strength was labeled only on a per mL basis, with the volume of the vial appearing in a different location.

  • Safety Brief: Label change for morphine injection. Several pharmacists and nurses have contacted us regarding a recent label change to Hospira’s morphine injection. The product is now labeled for intravenous (IV) use only. This is no doubt related to the US Food and Drug Administration (FDA) requesting new drug applications for certain grandfathered drugs.

  • Safety Brief: New tools on safe injection practices. The Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition (SIPC), of which ISMP is a member, released a suite of new materials last week to make it easier for doctors, nurses, and other healthcare providers to learn about and follow safe injection practices (

  • Safety Brief: Benadryl dispensed instead of vitamins for home PN. 47-year-old woman with a history of multiple gastrointestinal surgeries continued to experience severe nausea, vomiting, and chronic abdominal pain, requiring daily parenteral nutrition (PN). The patient’s home infusion company made and delivered the weekly supplies along with the 3-in-1 PN admixtures. But rather than dispensing the vials of multivitamins (which the patient adds at home), they inadvertently dispensed 84 vials of diphenhydrAMINE injection (BENADRYL).

  • ISMP webinar. Join us on December 18 for our last webinar of the year, Improving Medication Safety Through Staff Education and Competency Assessment: An Important Challenge for Healthcare Organizations. Join us on January 10 for our first webinar of 2013, Taking Charge when Drug Shortages Arise: A Model for Decision Making and Action. For details about both webinars, please visit:

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