The following are excerpts from the newsletter

June 5, 2014

In this week's issue:

  • Misidentification of alphanumeric symbols
  • Reminder: Take ISMP's survey on high-alert drugs.
  • FDA Bar Code Rule exemption leads to mix-up.
    • While preparing a trisodium citrate 0.5% solution as part of continuous venovenous hemodiafiltration (CVVHDF), Anticoagulant Citrate Dextrose Solution Formula A was used instead of Anticoagulant Sodium Citrate Solution 4%. Both products have similar names and packaging, and unlike other substances in sterile bags, neither item has a barcode.
  • Limit magnesium sulfate premix to 20 g bags.
    • A patient experienced seizures and a cardiac arrest after receiving magnesium sulfate instead of potassium chloride. Pharmacy staff had recently added 40 g magnesium sulfate bags to an ADC, in an area that previously held bags of 0.45% sodium chloride injection with 20 mEq of potassium chloride. 

Special announcements...

  • ISMP's Annual Fund
    • The healthcare community would be very different without ISMP's existence over the last 20 years. (For a list of ISMP's many important contributions to safety, please visit: We depend on the caring individuals and organizations that passionately support our work. Your charitable donation to the Annual Fund will help keep ISMP an important part of the fight against preventable medication errors.
    • To make a donation, go to:
  • ISMP webinars
    • Join us for our June 26 webinar, 2014 Update on the Joint Commission Medication-Related Standards. Learn directly from The Joint Commission leadership about medication management standards and medication-related National Patient Safety Goals that have proven to be the most difficult to achieve. Frequent challenges with the standards will be presented along with examples of how to achieve compliance in these troublesome areas.
    • Join us for our July 16 webinar, The Pharmacist's Role in Protocol-Driven Care for Pain Management, Nutritional Support, Anticoagulation, and More! Many pharmacists work collaboratively with physicians to provide protocol-driven care in an effort to improve patient outcomes. Join our guest speakers as they discuss the pharmacist's role in protocol-driven care for treatment modalities such as pain management, nutritional support, anticoagulation, and various other drug therapies.
    • For details, visit:

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