The following are excerpts from the newsletter

October 23, 2014

In this week's issue:

  • A crack in our best armor: "Wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning
  • Caution: "Per liter" content on manufacturer's IV bag labels.
    • ISMP recently received a report of a dosing error that resulted in the preparation of a 6% sodium chloride product instead of the 3% product ordered due to a miscalculation. Calculation errors have occurred because electrolyte concentrations are listed on IV bags as per 1000 mL instead of per container volume.
  • FDA proprietary drug name draft guidance.
    • The FDA has published a draft guidance for best practices in developing proprietary drug names. While ISMP supports this guidance, we also call for the agency to address the issue of over-the-counter (OTC) drugs and umbrella names (brand name extensions). Misleading product names have led to wrong product errors. 
  • Insulin pen error.
    • Improper injection techniques when administering insulin glargine using a pen device have occurred. In the cases discussed in this article, the prescribed units of insulin were properly dialed up but no units were actually administered. 
  • Possible dosing dilemma for infants.
    • The US FDA now recognizes that there may be situations where the benefit-risk profile of REVATIO (sildenafil) may be acceptable for certain children with pulmonary arterial hypertension (PAH) and they have clarified an earlier warning against the use of this drug. However, safety concerns exist regarding the ability to provide accurate doses for pediatric patients prescribed the commercially available liquid formulation of Revatio. 
  • Quarterly Action Agenda  (July - September 2014)

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 Activities at the ASHP Midyear Meeting
    • ISMP Medication Safety INTENSIVE (MSI):
      • Friday and Saturday, December 5 & 6, (Day 1, 7:30 a.m. - 4:30 p.m.; Day 2, 7:30 a.m. - 3:30 p.m.)
      • Business Expo Center, 1960 South Anaheim Way
      • Register online at:
    • Symposia: Register online at:
      • Improving Medication Safety in the Radiology Setting: Monday, December 8, 6:45 a.m.; Hilton Anaheim, Pacific Ballroom D
      • Addressing a Trifecta of Overlooked IV Medication Risks: Monday, December 8, 11:30 a.m.; Hilton Anaheim, Pacific Ballroom D
      • Recognizing and Responding to Serious Safety Concerns with Subcutaneous Insulin: Tuesday, December 9, 11:30 a.m.; Hilton Anaheim, California Ballroom D
      • Improving Medication Safety in the Perioperative Setting: Wednesday, December 10, 11:30 a.m.; Hilton Anaheim, Pacific Ballroom D
    • 17th Annual Cheers Awards Dinner:
    • ASHP Education Session:
      • Improving Medication Safety: A National Perspective from ISMP
      • Wednesday, December 10, 8:00 a.m. - 9:45 a.m.
      • Hilton Anaheim, Ballroom A
    • Exhibit: 
      • ISMP will be at booth 682 in the Anaheim Convention Center exhibit hall Monday to Wednesday, December 8-10

Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas
  - Free Nursing CEs
Special Alerts
Group Purchasing Subscription
Newsletter Editions
Acute Care
Community/Ambulatory Care
Nurse AdviseERR
Long-Term Care AdviseERR
Safe Medicine
Home | Contact UsEmployment  |   Legal Notices | Privacy Policy | Help Support ISMP
 Med-ERRS | Medication Safety Officer Society Medication Safety Officers Society | Consumer Medication Safety For consumers
ISMP Canada | ISMP Spain  | ISMP Brasil  | International Group  | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved