The following are excerpts from the newsletter

December 12, 2013

Happy Holidays...We wish you joy, health, and happiness this holiday season!

In this week's issue:

  • The 16th Annual CHEERS Awards: Feel the Rhythm of Change in Medication Safety
  • ISMP to launch a national safety initiative in 2014 
  • Are 10 mL syringes needed when giving drugs via venous access devices?
    • There is confusion about the syringe size needed for IV drug administration via venous access devices (VAD).  ISMP clarified this issue with the Infusion Nursing Society (INS) and a representative from Bard Access Systems. Please see article for important details.
  • Use of "NoAC" abbreviation.
    • The recent increased use of the abbreviation “NoAC” has been causing confusion. Check out how this abbreviation can result in patient harm if misinterpreted.
  • Unsafe frequency notation (Daily06 and Daily08).
    • Some electronic medical records list medication times as “Daily06” or “Daily08” indicating the time of day the medication should be given, not the frequency. This has led to a few close calls when patients are transferred to other facilities.
  • The first edition of our 2014 newsletters will be published and distributed on January 16, 2014 - See you next year!

Special Announcement...

  • 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:

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