The following are excerpts from the newsletter

September 25, 2014

In this week's issue:

  • QuarterWatch Report (Quarters 2 and 3, 2013): Signals for Chantix, Xyrem, Gilenya, and Tecfidera
  • DOCEtaxel product has unusual concentration
    • ISMP received a report of a dosing error associated with the use of the DOCEFREZ brand of DOCEtaxel. While most DOCEtaxel solutions are available as a 10 mg or 20 mg per mL concentration, this brand product results in a higher concentration per mL upon reconstitution and this is not clearly communicated on the product label.
  • Tragic vaccine diluent mix-ups in Syria have also happened here.
    • Errors similar to the reported mix-ups of vaccine diluent with neuromuscular blockers in Syria have happened in other countries, including the US, primarily due to confusion over look-alike vials and ampules. This article provides examples of some errors that have happened along with our suggestions for minimizing the risk in your organization. 
  • Caution when prescribing Xarelto to first-time patients.
    • ISMP received a report of an error associated with unclear instructions for a patient prescribed both strengths of XARELTO following discharge for a hospital. The patient took both strengths for several days before the error was discovered. Unfortunately, there were several missed opportunities to prevent this error before it reached the patient. This article highlights the need for healthcare providers to appropriately educate patients, especially for high-alert medications like anticoagulants. 
  • Welcome 2014-2015 ISMP Fellows
      • Ivyruth Andreica, BSN, PharmD, is the 2014-2015 ISMP Safe Medication Management Fellow, sponsored by Express Scripts Foundation.
      • Ariane Conrad, PharmD, BCACP, CDE, FASCP, is the 2014-2015 FDA/ISMP Safe Medication Management Fellow.
      • Read more about our Fellows in the newsletter or on our website.

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 October 23, 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 Anaheim, CA on December 5-6, immediately preceding ASHP Midyear Meeting. 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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