The following are excerpts from the newsletter

July 25, 2013

From the hospital to long-term care: Protecting vulnerable patients during handoffs

Safety Brief: Never prelabel containers. 

A bag of normal saline was labeled DIGIFAB in anticipation of the vials being delivered from pharmacy.  ISMP advises against prelabeling medication containers, due to the potential for improperly labeled products resulting in patient harm.

Safety Brief: “FASTIN” dietary supplement.
Phentermine is the active ingredient for prescription ADIPEX-P, and was also the active ingredient for the now discontinued prescription product “FASTIN”.  The brand name Fastin, is now being reused for several over-the-counter (OTC) products, none of which contain phentermine, and may result in confusion for patients and practitioners.

Safety Brief: FLEET Enema Saline-not just “saline”.
FLEET Enema Saline laxative, contains the active ingredients sodium phosphate monohydrate 19 g and dibasic sodium phosphate 7 g.  As a result of the product label, the phosphate content may be overlooked, leading to potential safety issues.

Safety Brief: Brand name exploitation. What’s in a name?
Sanofi company, introduced two new over-the-counter (OTC) ALLEGRA products last month, ALLEGRA ANTI-ITCH COOLING RELIEF and ALLEGRA ANTI-ITCH INTENSIVE RELIEF. Neither product contains the active ingredient fexofenadine, and can lead to medication errors if the actual contents aren’t recognized.

Special Announcements...

  • FREE LTC newsletter
    • Thanks to partial sponsorship from Lilly, we will now be able to offer our newest newsletter, Long-Term Care Advise-ERR, FREE to long-term care facilities! For details, visit:
  • ISMP Cheers Awards!
    • Nominations for this year's Cheers Awards will be accepted through September 14, 2013. The prestigious Cheers Awards honor individuals, organizations, companies, and agencies that have set a standard of excellence in preventing medication errors during the previous year. For information or to submit a nomination, please visit:
  • ISMP webinar.
    • Join us on August 15 for Outsourcing Sterile Compounding: Proposed Regulations and Safety Considerations. Speakers will discuss regulations and accreditation requirements for compounding pharmacies, in-house preparation versus outsourcing, and quality measures to consider when selecting an outsourcing company.
    • For details, please visit:
  • Medication Safety Checkup... (
  • Remember to take our survey on disrespectful behavior in healthcare by August 30, 2013; go to:

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