The following are excerpts from the newsletter

October 9, 2014

In this week's issue:

  • The "Dirty Dozen" 12 persistent safety gaffes that we need to resolve!
  • Scanning issue during Meditech bedside barcode verification
    • A hospital recently notified us of a flaw in the Meditech Bedside Medication Verification (BMV) system. Learn more about the issue and how to ensure errors do not happen at your organization.
  • ISMP seeks stronger CHANTIX warnings.
    • ISMP in addition to four other nonprofit organizations has submitted a citizen petition to the FDA to strengthen the Boxed Warning on Chantix. To view the petition, go to: 
  • Take our survey
    • We are repeating the survey on targeted medication safety best practices to evaluate progress. Please see the questions and link to the survey.  (
  • Delay in introducing new feeding tube connectors.
    • The release of new ENFit connectors on feeding tube administration sets will be delayed until the first quarter of 2015 due to product manufacturers awaiting FDA clearance. 
  • VISIONBLUE confused with methylene blue.
    • A mix-up between VisionBlue (trypan blue) and methylene blue left a patient blind. Assess your perioperative areas so you can prevent this mix-up from occurring in your organization. 
  • Clarification regarding insulin vials.
    • The Joint Commission issued a Sentinel Event Alert indicating that a vial can only be used more than once if it is clearly labeled. Insulin vials are an exception, but need manufacturer verification. 
  • Join ISMP in recognizing National Hospital and Health-System Pharmacy Week 

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, 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:
  • Help with product safety testing
    • If you are a pharmacist, nurse, unit clerk, pharmacy technician, or other healthcare practitioner who is interested in furthering medication safety, you can make a difference! Med-ERRS (a subsidiary of ISMP) is looking for assistance to help evaluate medication labels, drug packaging, and proposed drug names prior to submission by pharmaceutical and biotech companies for approval by FDA. The process is simple and fun, and a small honorarium is paid.
    • For details, visit:, and click on Become A Reviewer

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