The following are excerpts from the newsletter

July 3, 2014

In this week's issue:

  • We have a new look(the PDF version of our newsletter has a fresh new look)
  • Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications
  • Confusion between NAROPIN for epidural infusion and OFIRMEV IV.
    • Look-alike glass infusion bottles of NAROPIN (ropivacaine) injection and OFIRMEV (acetaminophen injection) have been confused when stored near each other even though labels clearly indicate the bottle content. Recommendations to decrease the risk of confusion between these products are included in this safety brief.
  • Baxter DOBUTamine overwrap label change questioned.
    • Changes to the overwrap labels on Baxter’s premixed bags of DOBUTamine led to a close call. Review the safety brief for more details about the issue and note the recommended strategies to prevent this mix-up from occurring in your organization.
  • PEMEtrexed vials contain overfill.
    • Once reconstituted, ALIMTA (PEMEtrexed) has a final concentration of 25 mg/mL. Due to overfill that is not specified in the package insert, the total volume needed to deliver a dose may be obtained from fewer vials of drug than anticipated. Review this safety brief for more specifics on this issue. 

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 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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