The following are excerpts from the newsletter

August 22, 2013

Developing productive partnerships with technology and device vendors to improve staff training

In this week's issue:

Dinoprostone dosage forms confused.

Recently, an error occurred when a PROSTIN E2 (dinoprostone) 20 mg vaginal suppository was cut in half and used in place of CERVIDIL (dinoprostone) 10 mg vaginal insert.  The generic name for both products is the same and does not indicate the products have different pharmacokinetic properties. 

Pharmacy compounder won't recall products; FDA warns, "don't use."

NuVision pharmacy of Dallas, Texas has repeatedly declined FDA’s request to recall its sterile products, after a recent FDA inspection revealed poor sterile production practices. The FDA has stepped up efforts to gain specific authority to regulate pharmacies that act more like a large-scale manufacturer than a compounding pharmacy.

Sterile compounding bill.

Senate bill S. 959 would allow compounding of commercially available drugs, on the FDA shortage list, under a new category of compounder called “compounding manufacturers.” ISMP intends to work with legislators during the regulatory process, to ensure regulations require strict adherence to quality standards.

Acetaminophen dosing for kids younger than 2.

Currently, the labeling of acetaminophen for children 6 months to 2 years includes only an “ask a doctor” statement in the dosing directions. Children can spike a fever at any time of the day or night, prompting parents to seek dosing information from a healthcare professional rather than from the Drug Facts label.

RCA team training. 

ISMP is a certified Patient Safety Organization, available to conduct on-site team training in error investigation and root cause analysis (RCA). For information, please call 215-947-7797 or send a request to:

Special Announcements...

  • 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 September 10 for Raising the Bar for BCMA: Addressing Pharmacy Challenges, Nursing Engagement, and Data Analysis to Improve Practice. Two organizations with different electronic health record vendors describe how they optimized the use of barcode medication administration (BCMA).
    • For details, please visit:
  • Free ISMP webinar.
    • ISMP will be offering a FREE webinar funded by Baxter on October 24, Preventing Catheter and Tubing Misconnections: Risk Assessment and Interventions that Work. Learn about a free tool to assess your risk for tubing misconnections and key interventions that have been successfully implemented in hospitals.
    • For details, please visit:
  • Unique 2-day program.
    • Attend ISMP's Medication Safety INTENSIVE workshop in Scottsdale, AZ, on October 3-4. This workshop provides hands-on experiences with risk assessment, event investigation, error analysis, Just Culture, action planning, and more!
    • 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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