The following are excerpts from the newsletter

May 22, 2014

In this week's issue:

  • Administering just the diluent or one of two vaccine components leaves patients unprotected
  • Dosing error with TASIGNA.
    • Preprinted dosing instructions on the manufacturer’s packaging may lead to dosing errors with TASIGNA (nilotinib).
  • Repackaging of IMBRUVICA is OK.
    • Recently approved drug has confusing dosing and packaging instructions. However, repackaging the drug to dispense is okay. 
  • Posaconazole dose depends on dosage form.
    • Late in 2013, new dosage forms of this drug became available. If various forms are available at your institution, clinical alerts may help prevent ordering the incorrect dose.
  • 3,100 patients notified of pen reuse.
    • Insulin pen reuse continues to be a problem – don’t assume all practitioners know about this risk!

Special announcements...

  • ISMP webinar
    • Join ISMP for our June 26 webinar, 2014 Update on the Joint Commission Medication-Related Standards. Learn directly from Joint Commission leadership about medication management standards as well as medication National Patient Safety Goals that prove to be the most difficult to achieve for hospitals and healthcare systems. Frequent challenges with the standards will be presented along with examples of how to achieve compliance in these troublesome areas.
    • For details, visit:
  • Unique 2-day program
    • Attend ISMP's Medication Safety INTENSIVE workshop in Las Vegas on May 30-31. This workshop provides hands-on experiences with event investigation, risk analysis, error-reduction strategies, action planning, Just Culture, and more!
    • For details, visit:

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