The following are excerpts from the newsletter

June 19, 2014

In this week's issue:

  • Some IV medications are diluted unnecessarily in patient care areas, creating undue risk
  • Vancomycin injection for oral use given IM
    • We recently received a report from a long-term care (LTC) pharmacy that discovered administration errors involving vancomycin for the treatment of Clostridium difficile infections. Nurses at two LTC facilities were unfamiliar with the practice of using injectable vancomycin for oral administration. We describe our recommendations for preparation of this product and providing clear instructions for administration.
  • In deepest sympathy...remembering one of the first full-time Medication Safety Officers and creator of the "Do Not Crush" list, John F. Mitchell, PharmD
  • Phenylephrine injection needs dilution for IV bolus use.
    • There is confusion surrounding the preparation of bolus doses of phenylephrine and we received a report of a close call due to this confusion. The report, and information about phenylephrine hydrochloride 10 mg/mL, 1 mL vials, is described in this SafetyBrief. 
  • Similar drug names confused. (BRINTELLIX [vortioxetine] and BRILINTA [ticagrelor])
    • A physician was attempting to electronically prescribe BRINTELLIX (vortioxetine) 10 mg daily, but after typing the first few letters of the brand name into the computer system, he incorrectly selected BRILINTA (ticagrelor). Recommendations to minimize the chances of a similar error occurring in your organization are described.
  • Trace element shortage survey data available.
    • The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) conducted a survey to learn more about how clinicians are managing the ongoing shortage of IV trace elements. The results of the survey and some take away messages can be found in a report, available at:
  • SS (or SSc) - an error-prone abbreviation.
    • Despite the fact that the abbreviation SS appears on ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (, we recently received an error report involving the use of the abbreviation SSc to communicate dosing instructions for an insulin product. 
  • CMS: Follow up on infection control breaches.
    • CMS recently issued a memo describing infection control breaches which warrant referral to public health authorities. The memo can be found at: 
  • Unusual use for a baby bottle nipple.
    • We received a report describing the use of a baby bottle nipple to apply lidocaine 4% cream to numb the procedural area prior to a newborn infant circumcision. The scenario and recommendations for this procedure are described in further detail. 

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:
  • Unique 2-day program
    • Attend ISMP's Medication Safety INTENSIVE workshop in Nashville, TN on October 2-3. 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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