The following are excerpts from the newsletter

November 6, 2014

In this week's issue:

  • Strengthen your resolve: No unlabeled containers anywhere, ever!
  • Propylene glycol toxicity with "stoss" therapy.
    • When treating nutritional rickets with high-dose vitamin D (stoss therapy), unintentional outcomes may result. Learn what strategies can be implemented to avert this potentially fatal outcome.
  • State drug tracking database helps prevent an error.
    • Many pharmacists are now familiar with prescription databases, implemented to reduce prescription misuse. In this issue, see how a pharmacist was able to avert a major medication error involving fentaNYL 100 mcg patch. 
  • Where did this come from? (medications not purchased by pharmacy found in hospital supply)
    • We received a report in which a hospital found a product containing heparin circulating on the floors even though it was not dispensed from the pharmacy. Read more on how you can protect your hospital from acquiring unauthorized medications. 

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 Symposia at the ASHP Midyear Meeting
    • Improving Medication Safety in the Radiology Setting: Monday, December 8; 6:15 a.m. breakfast; 6:45 a.m. Symposium
    • Addressing a Trifecta of Overlooked IV Medication Risks: Monday, December 8; 11:30 a.m.
    • Recognizing and Responding to Serious Safety Concerns with Subcutaneous Insulin: Tuesday, December 9; 11:30 a.m.
    • Improving Medication Safety in the Perioperative Setting: Wednesday, December 10; 11:30 a.m.
    • For more information and to register, go to:
  • Unique medication safety opportunity at FDA
  • Unique 2-day program
    • Attend ISMP's Medication Safety INTENSIVE workshop in Anaheim, CA on December 5-6. 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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