The following are excerpts from the newsletter

August 8, 2013

Fentanyl patch fatalities linked to "bystander apathy"

Safety Brief: Help end hepatitis B.
Nearly one in three US newborns leave the hospital unvaccinated against hepatitis B despite experts agreeing that hepatitis B can be eliminated in the US, and that vaccination at birth is fundamental to this effort. A vaccine birth dose should be part of standard order sets and universally administered before hospital discharge.

Safety Brief: Liter or hour?
A pharmacist had to clarify an order after a nurse documented an oral order for a liter of 0.9% sodium chloride injection to be administered at 150 mL per hour where the abbreviation “ltr” for liter looked like “Hr.” ISMP will consider adding “ltr” to our list of confusing abbreviations.

Safety Brief: Confusion a “factor” with “PCC” orders.
The terms “Prothrombin Complex Concentrate” and “PCC” are often used for several different products. ISMP recommends reviewing all reversal products on the formulary, educating practitioners on the appropriate use of these agents, and clarifying all orders for “Prothrombin Complex Concentrate” or “PCC.”

Safety Brief: Help on the way to prevent catheter misconnections.
ISMP has repeatedly covered issues with misconnections between various catheters, syringes, and tubing used in healthcare over the years. Now, thanks to combined efforts of the device industry, regulators, and other experts, new standards will render direct misconnections nearly impossible once these connectors reach the market.

Safety Brief: GlycoTrol or Glucotrol?
A patient had to be readmitted to the hospital after transferring to a long-term care facility due to receiving GLUCOTROL (glipiZIDE) instead of the dietary supplement “Glycotrol.” Including the indication for all medications during medication reconciliation and confirming that the patient is taking an oral antidiabetic agent prior to administration may have prevented this error.

Special Announcements…

  • ISMP webinars
    • Join us on August 15 for Outsourcing Sterile Compounding: Proposed Regulations and Safety Considerations. Speakers will discuss regulations and accreditation requirements for hospitals using outsourced sterile products and quality measures to consider when selecting an outsourcing company.
    • Join us on September 10 for Raising the Bar for BCMA: Addressing Pharmacy Challenges, Nursing Engagement, and Data Analysis to Improve Practice. During the webinar, you will learn firsthand as two organizations with different electronic health record vendors describe their journey of advancing medication safety through optimization of barcode medication administration (BCMA). 
  • Conference
    • Diagnostic errors compete with medication errors as the leading threats to patient safety today. What can be learned from the medication safety community that can be applied to reduce the risk of diagnostic errors? The September 22-25 Diagnostic Error in Medicine conference will bring together stakeholders with a shared goal of improving patient safety. For details, please visit:

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