The following are excerpts from the newsletter

September 19, 2013

In this week's issue:

  • Small effort, big payoff...Automated maximum dose alerts with hard stops
  • Pump resumes PCA dosing when turned off then on again
    • We received a report where a pediatric patient on morphine patient-controlled analgesia (PCA) using a CADD-Solis Ambulatory Infusion Pump received additional PCA doses after the nurse had turned the pump off but not disconnected the patient from the pump. The patient had turned the pump back on and administered 2 mg bolus doses every 15 minutes. We discuss several possible options to address this issue.
  • Mix-ups reported with B. Braun heparin bags.
    • Several B. Braun premixed heparin bags look similar and ISMP has received reports of errors with these products. The latest error report as well as some promising new product information is reviewed in this Medication Safety Alert! newsletter. 
  • Safe ways to restock ADCs.
    • A nurse trying to retrieve enalaprilat injection from an automated dispensing cabinet in the intensive care unit discovered a vial of vasopressin mixed in the same pocket with the enalaprilat vials. While barcode scanning during restocking occurs, only one of the numerous vials to be restocked was scanned. Recommendations to help prevent similar errors during the restocking of ADCs are offered in the newsletter. 
  • ISMP resources and services (Sterile Compounding Analysis, RCA Team support, and more -
Special Announcements...
  • 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:
  • Job opening at FDA.
    • Our colleagues in the Division of Medication Error Prevention and Analysis (DMEPA) in the Office of Surveillance and Epidemiology at FDA's Center for Drug Evaluation and Research are recruiting a pharmacist, nurse, nurse practitioner, physician assistant, or others with patient safety experience to serve as a Safety Evaluator at their campus in Silver Springs, MD. If you are interested in making a difference in protecting the health of the American people, go to for further information.


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