The following are excerpts from the newsletter

November 14, 2013

In this week's issue:

  • Understanding and managing IV container overfill 
  • Traveling infusion pump.
    • We recently received a report in which a nurse called the pharmacy because she was unable to locate a medication in the infusion pump’s drug library. After further investigation, it was discovered that the pump did not belong to the hospital and had been brought into the facility during a patient transfer from another hospital. Recommendations for managing this scenario, as well as similar situations with rental pumps are discussed in this newsletter. 
    • ISMP has received several reports of mix-ups with CARDENE (niCARdipine) and CARDIZEM (diltiazem). Recommendations for preventing drug name mix-ups like these can be found in our August 9, 2007 issue ( These two drug names will be added to our list of commonly confused drug names and an updated list will be published early next year. 
  • FAQs about initiative to eliminate tubing misconnections.
    • An international effort is underway to standardize the various types of connectors used in healthcare, making them incompatible with each other. The Association for the Advancement of Medical Instrumentation (AAMI), the International Organization for Standardization (ISO), and other key stakeholders from a joint working group have posted an FAQ to answer questions about the project. 
  • International medication safety group meets.
    • The International Medication Safety Network (IMSN) is an international network of medication safety organizations and safety experts from more than 20 countries. The group held its eighth annual meeting in Paris, France in October and recommended strengthened regulations for medication naming, labeling, and packaging. IMSN invited regulators and other key stakeholders to join the group at a summit in 2014 to discuss these issues. 
  • Potential dose confusion.
    • Many computer systems make it difficult to properly communicate the dose of SPIRIVA (tiotropium). Practical recommendations for entering orders for Spiriva are discussed. 

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.
    • Join us on December 19 for New Actions by FDA to Reduce Medication Errors Tied to Manufacturer’s Container Labeling. Our speakers will describe several medication errors associated with ambiguous labeling and packaging, list three guidances in the FDA document that will positively impact the safety of labeling and packaging, and discuss the importance of the FDA document in product purchase evaluation.
    • For details, please visit:
  • ISMP Activities at the ASHP Midyear Meeting:
    • 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:
    • Exhibit.
      • Monday, December 9 - Wednesday, December 11: ISMP will be at booth 1352 in the Orlando Convention Center exhibit hall.
    • 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:
    • CHEERS Awards.
      • Join us at Cuba Libre, Pointe Orlando, 9101 International Drive, Orlando, on December 10, from 6 p.m. - 9:30 p.m. as we celebrate this year's CHEERS AWARDS winners! Register online at

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