The following are excerpts from the newsletter

July 31, 2014

In this week's issue:

  • Safety requires a state of mindfulness
  • Misleading Kcentra label leads to dosage errors
    • Although the Kcentra carton label seems to indicate that each vial contains 500 units, there is actually a range of Factor IX units in each vial. Learn how this information was discovered, and how to familiarize yourself and your staff about this issue to prevent dosing errors at your facility.
  • Positive change, negative consequence.
    • Although the product label may clearly indicate the medication dose and frequency, these manufacturer instructions may be different than those prescribed. It is important that the pharmacy label is attached to the bottle that is dispensed and that the patient is educated about how to properly take the medicine.  An example of this type of error is discussed in this Safety Brief. 
  • Updated High-Alert Medications List.
    • We recently updated our List of high-alert medications. Go to to access the new list.

Special announcements...

  • ISMP Cheers Awards! Look at How Far We've Come
    • Nominations for this year's Cheers Awards will be accepted through September 14, 2014. The prestigious Cheers Awards honor individuals, organizations, companies, and agencies that have set a standard of excellence in preventing medication errors during the previous year. For information or to submit a nomination, please visit:
  • 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 webinar
    • Join us on September 18, 2014 for our webinar, Beyond Medication Error Reporting: A New Approach for Understanding Medication Safety Risk. Voluntary error reporting is just the tip of the iceberg when it comes to understanding medication safety. Identifying and measuring the level of risk within a system and understanding the reliability of processes is fundamental to safety improvement. During the webinar, participants will learn how to identify medication safety risks using methods beyond error reporting. Various approaches for collecting proactive, concurrent, and retrospective data will be discussed.
    • 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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