The following are excerpts from the newsletter

June 27, 2013

Disrespectful behavior in healthcare...
Have we made any progress in the last decade?

Please take our survey on disrespectful behavior in healthcare by going to

Long-Term Care Advise-ERR, a new Medication Safety Alert! newsletter for nurses and administrators in long-term care facilities. Go here  for more information! 

Join us on July 18 for Measuring Medication Safety: Using the Right Data for the Best Results. This webinar will look at ways to measure medication safety, identify problems, and determine if improvement efforts have been successful.

Medication Safety Checkup. The Institute for Safe Medication Practices (ISMP) offers a 1-day, onsite, customized risk assessment that can help organizations quickly address specific medication safety challenges. For more information about the Medication Safety Checkup, please visit:

Safety Brief: Two error-reduction principles with one change. We recently heard of a situation where a vial of 50 mL of lidocaine was retrieved from an automated dispensing cabinet (ADC) instead of what was thought to be a 50 mL vial of 50% dextrose. There are several basic principles that can help to reduce harm from medication errors with high-alert drugs.

Safety Brief: Read the NAN Alerts! ISMP highly recommends that professional staff who handle medications in all healthcare settings to read the NAN Alerts. The NAN Alerts are published by ISMP and the American Society of Health-System Pharmacists (ASHP).

Safety Brief: Leucovorin-levoleucovorin mix-up. Two errors occurred at a hospital involving a mix-up between leucovorin and levoleucovorin. Due to the similarity in the name, there is significant potential for dosing errors when interchanging leucovorin and levoleucovorin.

Safety Brief: Errata. There is an incorrect statement regarding FENTORA (fentaNYL buccal tablets) tablets in the table “Oral Dosage Forms That Should Not Be Crushed” on the ISMP website ( The tablet should not be swallowed whole as this may not provide adequate pain relief.

Special Announcements: ISMP Cheers Awards! Nominations for this year’s Cheers Awards will be accepted through August 31, 2013. For more information, please visit:

Special Announcements: ISMP webinars. ISMP will be holding webinars titled Measuring Medication Safety: Using the Right Data for the Best Results on July 18, 2013 and Outsourcing Sterile Compounding: Proposed Regulations and Safety Considerations on August 15, 2013.  For details about both webinars, please visit:

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