The following are excerpts from the newsletter

October 31, 2013

 Happy Halloween!!!

In this week's issue:

  • As U-500 insulin safety concerns mount, it's time to rethink use of strengths above U-100 
  • Take our survey on the shortage of PN ingredients
    • ISMP is conducting a survey to determine how the shortage of parenteral nutrition (PN) ingredients has affected healthcare providers and patients and whether any errors have resulted from the shortage. Please complete the survey by December 6, 2013, at:
  • Improved labeling needed for camphor product
    • Clearer labeling that specifies topical camphor products are for external use only is needed to reduce the risk of oral ingestion of topical camphor products.
  • ECRI Institute PSO partners with ISMP
    • The partnership announced earlier this week between ISMP and ECRI Institute PSO will enhance analysis of events to make healthcare safer.
  • Archaic apothecary strengths confused.
    • There is risk for errors due to the expression of strength in both mg and the apothecary measure, gr (grains), for certain products. Strength expressed in gr (grains) could be confused with g (grams).
  • On the other hand... (performing an independent check alone)
    • Here is a practical recommendation to perform an independent double check while working alone.
  • Message in our mailbox: Another source of topotecan errors.
    • A widely used reference for renal dose adjustments recommends decreasing the dose of topotecan in patients with impaired renal function, however, the reference incorrectly lists the dose for topotecan in patients with normal renal function. 

Special Announcements...

  • ISMP Fellows.
    • ISMP welcomes Millie Brahmbhatt, PharmD, BCPS, the 2013-2014 FDA/ISMP Safe Medication Management Fellow. Millie joins us from Edward Hines, Jr. VA Hospital, located near Chicago, IL, where she practiced as a Clinical Pharmacy Specialist in geriatrics and anticoagulation. Also newly arrived is Dalia Alghamdi, BSc Pharm, MSc HCPM. Dalia, our International Fellow, is from Prince Sultan Medical Military City in Riyadh, Saudi Arabia where she was the medication safety officer responsible for the development, implementation, and administration of all environment, health, and safety functions. These newest Fellows join Amanda Wollitz, PharmD, the Stephen R. Lewis, MD, Fellow, sponsored by the CareFusion Foundation, and Michael O’Connor, PharmD, MS, our ISMP Fellow, sponsored by Express Scripts. Mandy and Mike started at ISMP this past summer. Mandy is from Baptist Medical Center in Jacksonville, FL, where she practiced as a clinical pharmacist in various areas such as emergency medicine, oncology, and internal medicine. Mike joined ISMP from The Ohio State University Wexner Medical Center in Columbus, OH, after completing a combined 2-year residency program and master’s degree. ISMP Fellows spend a full year working with ISMP staff at the organization’s headquarters in Horsham, PA. The FDA/ISMP Fellow spends 6 months with ISMP followed by 6 months at the FDA.
  • 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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