The following are excerpts from the newsletter

October 3, 2013

In this week's issue:

  • Unresolved disrespectful behavior in healthcare Practitioners speak up (again) - Part 1
  • Changes to heparin vial labels now in circulation.
    • Heparin container labels now list the total amount of drug per vial with the amount per mL immediately below it. During the transition period in which vials with the old labels and vials with the revised labels are both available, organizations should take steps to minimize the risk of confusion.
  • Anything missing from this label?
    • One generic manufacturer uses a coined abbreviation instead of the actual drug name (“isosorbide mononitrate extended release”) on the package label. 
    • Confusion occurred between LETARIS (a formerly marketed Dutch brand name for letrozole) and LETAIRIS (the US brand name for ambrisentan) when Letairis was misspelled as Letaris on a patient’s medication form.
  • Possible cross-contamination with insulin vials.
    • An insulin vial became contaminated when a nurse injected a patient with an empty insulin syringe and used the same syringe to drawn up insulin from the same vial for that patient. The insulin vial was then used to prepare doses for other patients.
  • Your Reports at Work
    • Difficulty seeing fentaNYL patches when worn by patients has been a common complaint. The FDA is now requiring manufacturers of transdermal fentaNYL to make changes to the writing on the patches so they can be seen more easily.  
  • Quarterly Action Agenda (July - September 2013) 

Special Announcements...

  •  ISMP webinars.
    • 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:
    • ISMP will be offering a FREE webinar funded by Baxter on October 24, Preventing Catheter and Tubing Misconnections: Risk Assessment and Interventions that Work. For details, visit:
  • ISMP Symposium
    • ISMP invites you to join us on December 9 for Midday Symposia #2: Improving the Safe Use of Opioids in the Acute Care Setting, which will be held during the ASHP Midyear Clinical Meeting in Orlando, FL. The symposia will be held from 11:30 a.m. to 1:30 p.m. in the Convention Center West, Room W102. Lunch will be provided.
    • Please register by December 5 at:
  • Medication Safety Checkup...(
  • Unique 2-day program.
    • Attend ISMP's Medication Safety INTENSIVE workshop in Orlando, FL, on December 6-7. This workshop provides hand-on experiences with risk assessment, event investigation, error analysis, Just Culture, action planning, and more!
    • For details, please visit: 

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