The following are excerpts from the newsletter

November 28, 2013

In this week's issue:

  • First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP)
  • Caution on Demo-Dose products from Pocket Nurse.
    • A demonstration product, supplied by Pocket Nurse, was found by a pharmacy technician during routine inspection of a code cart. This could have led to the delayed emergency treatment of a critically ill patient. Learn more about how to prevent demo products from getting mixed-up with real products. 
  • Influenza vaccine-shake well!
    • Injectable influenza vaccines need to be shaken before use according to the carton label. Staff need to be reminded since the vial and syringe labels are not labeled as such. 
  • Avandia, not Coumadin.
    • FDA lifts restrictions on AVANDIA which could rekindle mix-ups with handwritten orders of this drug and COUMADIN. 
  • Close call with wintergreen oil.
    • A prescriber found wintergreen oil on the drug list and ordered it to be placed at the patient’s bedside as an air freshener. Leaving a small bottle at the bedside could pose problems if the patient inadvertently thinks it is an oral liquid medication. 
  • Don't forget to take our survey! Take our survey on the shortage of PN ingredients ( 
  • Happy Thanksgiving!!!

Special Announcements...

  • ISMP webinar.
    • Join ISMP on December 19 for our final webinar of 2013, New Actions by FDA to Reduce Medication Errors Tied to Manufacturer's Container Labeling. Recently, FDA published an important draft document to help standardize the components of container labeling to address safety issues including abbreviations and symbols on product labeling, prominent company logos and clutter that distract from readability, warnings that aren't emphasized, and color patterns that lead to selection of the wrong container. Although the guidance is not a regulation, it provides FDA staff with information that should be considered when evaluating product safety. This information is also important for pharmacists and physician leadership on a pharmacy and therapeutics committee because it communicates the most important label components one should consider when evaluating products for purchase.
    • 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:
  • Cheers gala.
    • Join us at Cuba Libre, Pointe Orlando, 9101 International Drive, Orlando, on December 10, from 6 p.m. to 9:30 p.m. as we celebrate this year's CHEERS AWARDS winners! Register online at:

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