The following are excerpts from the newsletter

November 20, 2014

In this week's issue:

  • Unverified patient-reported error: A false alarm can have real consequences
  • Changes in enteral feeding device connectors.
    • Transition to the new, non-Luer connectors for feeding tubes and associated administration sets and syringes will begin during the first quarter of 2015. Unfortunately, many healthcare professionals are still unaware of the change and how the change will affect their work processes and patient care.
  • Lot number, not expiration date.
    • ISMP received a report of a nurse using an expired dose of lactulose solution because of the way the expiration date and lot number were expressed on the unit dose product manufactured by Pharmaceutical Associates. Similar events involving the company’s acetaminophen liquid and aluminum-magnesium hydroxide with simethicone liquid have been published previously. 
  • Remember to take our Resurvey on the 2014-2015 Targeted Medication Safety Best Practices for Hospitals at:

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:
  • MSOS Reception at Midyear
    • Join us on December 8, at the Anaheim Marriott from 5:30 - 6:30 p.m. for a Medication Safety Officers Society (MSOS) Reception sponsored by CompleteRx.
  • ISMP Fellowships
    • Interested in the ISMP Safe Medication Management Fellowship Programs? Stop by our booth (682) at the ASHP Midyear exhibit hall, December 8 - 10, to request more information.
  • Unique medication safety opportunity at FDA
  • HIMSS15 Conference & Exhibition
    • From April 12-16, 2015, more than 38,000 healthcare IT professionals, clinicians, executives, and vendors from around the world will join the Healthcare Information and Management Systems Society (HIMSS) at the McCormick Place in Chicago, IL, for the annual conference and exhibition. ISMP is serving again as an official endorser of the conference.
    • To learn more, go to:

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