The following are excerpts from the newsletter

July 11, 2013

In utero medication administration to fetus presents unique safety challenges

Syringe pull-back method of verifying IV admixtures unreliable. 
When multiple additives and syringes are being used for sterile compounding, there is the potential that the vials or syringes will be interchanged. Due to such possibility, this method is not a reliable indication of the amount of medication added to a compound...

Safety Brief: Ophthalmic container labels changing. Recently, an error occurred when tropicamide 1% eye drops, were filled instead of cyclopentolate 1% eyedrops. Due to similarity in packaging there is heightened potential for error with these products. 

Safety Brief: Evaluate available ketamine concentrations. A pediatric patient received a 10-fold overdose of ketamine, while receiving treatment in the emergency department. Concentrated ketamine products, which result in small volumes may be more appropriate for IM administration.

Safety Brief: Drug shortages and medication errors. A recent near miss with levothyroxine IV was a result of product replacement, as a consequence of a drug shortage. Hospitals should have a plan in place for how product replacements are used during a shortage, and how changes are communicated to staff.

Safety Brief: ISMP processes health IT error reports. The agency for Healthcare Research and Quality (AHRQ) will encourage event reporting, including health IT-related events to a federally certified Patient Safety Organization (PSO). The ISMP National Medication Errors Reporting Program (ISMP MERP) can be used for this purpose, and will help address significant situations.

Safety Brief: Greater than and less than symbols discouraged. The “greater than (>)” and “less than (<)” symbols continue to be used incorrectly or misunderstood. Using the words “greater than” and “less than” can prevent these errors from occurring.

Special Announcements: This month ISMP will begin to publish Long-Term Care Advise-ERR, a new Medication Safety Alert! newsletter for nurses and administrators in long-term care facilities. For details and to subscribe to the newsletter, visit:

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:

Dr. Senders retires. As Principal Scientific Consultant for ISMP, and a founding member of the Board of Directors of ISMP Canada, Dr. Senders helped to set the path we follow for the analysis of medication errors and associated prevention strategies. We will miss his professional expertise and contributions to patient safety.

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