The following are excerpts from the newsletter

October 17, 2013

In this week's issue:

  • QuarterWatch (2012 Annual Report): Anticoagulants, anti-TNF drugs, fentaNYL patches, and alendronate 
  • RABAVERT needs better packaging.
    • Recently, a pharmacy found a box of rabies vaccine (RABAVERT) in the refrigerator with the diluent vial but not the actual vaccine powder. This might have resulted in an ineffective vaccination if only the diluent was administered. 
  • Caution about PPD labels.
    • On two occasions, when a 5 unit dose of tuberculin purified protein derivative (PPD) was ordered, a pharmacy inadvertently dispensed an entire 1 mL vial of tuberculin 5 units/0.1 mL (10 doses). The vial’s front label panel states only 5 units/0.1 mL and one must turn the vial around to see additional information that notes there are 10 doses in the vial. 
  • Toolkit for smart pump dose limits.
    • The San Diego Patient Safety Council posted a toolkit earlier this year to provide evidenced-based recommendations and best practices for setting up and managing high-alert IV medication dose limit settings. The kit provides a glossary of terms associated with smart pump use and drug-specific recommendations for implementing dosing limits in your institution. 
  • National Hospital and Health-System Pharmacy Week: October 20-26, 2013. 
    • Join ISMP in recognizing pharmacists and pharmacy technicians who work in inpatient, outpatient, home-care, and long-term care settings for the valuable services they provide and for all they do to help keep patients safe from harmful medication errors. (

Special Announcements...

  • ISMP webinar.
    • Join us on November 19 for Preparing for Biosimilars: Are You Ready to Safely Integrate Them Into the Medication Use Process? Our speakers will explain the regulatory landscape of biosimilars, compare them to generic small molecule drugs, discuss safety concerns with these products, and present a plan to incorporate biosimilars into practice.
    • For details, please 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:
  • Unique 2-day program.
    • Attend ISMP's Medication Safety INTENSIVE workshop in Orlando, FL, on December 6-7 (prior to the ASHP Midyear Clinical Meeting). This workshop provides hands-on experiences with risk assessment, event investigation, error analysis, Just Culture, action planning, and more! For details, visit:

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