The following are excerpts from the newsletter

September 5, 2013

In this issue:

  • FDA Advise-ERR: Avoiding topotecan ten-fold overdoses
    • The US Food and Drug Administration and ISMP have received several reports of medication errors involving 10-fold topotecan overdoses.  Several strategies for safe dosing of topotecan are discussed in this FDA Advise-ERR.
  • Update during a shortage.
    • Drug shortages have often resulted in having to use alternative strengths, dosage forms, or drugs.  It is important that institutions update all applicable informational resources and available technology to reduce the likelihood of error in these situations.
  • Heparin label placed on wrong bag.
    • ISMP received a report where heparin 120 units in 250 mL of 0.45% sodium chloride prescribed for an infant was mixed up with heparin 25,000 units/250 mL in 5% dextrose during the dispensing process. The pharmacy had been forced to compound heparin 25,000 units/250 mL in 5% dextrose due to a drug shortage and the label for the pediatric dose was affixed to the incorrect product.  By chance, this potentially harmful medication error was averted.
  • Activate this ADC setting.
    • A hospital reported a medication error where a patient received the scheduled morning medications on one unit, was transferred to another unit, and then received another dose of each of these scheduled medications.  The factors associated with this event and strategies to help prevent a similar event are discussed in this safety brief.

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 October 15 for Using Data to Pump Up Safety with Smart Infusion Devices. Our two speakers will share the keys to addressing specific patient-related and medication-related issues, overcoming integration and upload challenges, reducing alert fatigue, managing libraries and updates, and leveraging practitioners' engagement to support safety. 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... (

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