The following are excerpts from the newsletter

August 28, 2014

In this week's issue:

  • VARIZIG dilution problems reported
  • PROSTIN E2 suppository confused with progesterone
    • Storing similar products in patient care areas can lead to mix-ups. Learn how a mix-up between a Prostin E2 suppository and a progesterone suppository resulted in the unintended delivery of a pre-term infant.
  • FIRST brand oral vancomycin needs improved labeling
    • Products that need to be reconstituted need to be clearly labeled as such. Errors have occurred when the powder or the diluent alone have been dispensed. An example of oral vancomycin with unclear labeling is presented in this article. 
  • Nitroglycerin injection shortage issue.
    • Using products from different manufacturers during a drug shortage can cause confusion, especially if the information on the product label is expressed differently. Learn how easily this happened when a nurse misread the label on a premixed bottle nitroglycerin. 
  • New dantrolene product can improve safety.
    • A new formulation of dantrolene sodium was recently approved for the treatment of Malignant Hyperthermia. This new formulation is quicker to reconstitute and eliminates the need to stock liter bags of sterile water that can be accidentally administered intravenously. 
  • Clarification with ISOVUE.
    • Transferring Isovue from the Pharmacy Bulk Package (PBP) should be performed in a suitable work area, such as a laminar flow hood, utilizing aseptic technique. Read this Safety brief for more information. 

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 webinar
      • Join us on September 18, 2014, for our webinar, Beyond Medication Error Reporting: A New Approach for Understanding Medication Safety Risk. 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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