The following are excerpts from the newsletter

September 11, 2014

In this week's issue:

  • Be wary of "misspeakers" who "shoot from the hip"
  • Worth repeating... Water for inhalation confused as IV solution
    • ISMP recently received two reports involving CareFusion sterile water 1,000 mL bags for inhalation. The solution was accidentally administered intravenously due to the similar appearance to liter bags of IV solutions. We have repeatedly asked the company to address the issue; in the meantime, it is important for healthcare organizations to implement strategies to prevent this error.
  • Look-alike prefilled syringes.
    • ISMP has received reports of mix-ups between iSecure syringes manufactured by Hospira. Although their unique features differentiate them from other prefilled syringes, steps need to be taken to reduce the risk of mix-ups if more than one type or dose of medication in iSecure syringes are used in patient care areas. 
  • Compounded pain creams and adverse effects.
    • The use of special compounded pain creams is growing. However, there is no regulatory or licensing oversight monitoring how these pain creams are prepared and dispensed. Read more about our concerns with these products. 
  • PACU ADC selection error.
    • Specialty areas may be more at risk for errors when pharmacy is not involved. This article identifies strategies that one organization implemented in their PACU to prevent drug selection errors from happening again. 

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 on September 18, 2014, for our webinar, Beyond Medication Error Reporting: A New Approach for Understanding Medication Safety Risk. Identifying and measuring risk within a system 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.
    • Join us on October 23, 2014, for Smart Pump Integration: A Giant Step for IV Infusion Safety. This webinar will describe how smart pump integration can improve safety by linking the medication order directly to the infusion device and prepopulating the pump with infusion parameters contained in the order, thereby eliminating programming errors. Efficiencies are also gained as a 17-step manual programming process is reduced to 7 steps with integration.
    • 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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