The following are excerpts from the newsletter

December 18, 2014

Happy Holidays from the staff and trustees at the

Institute for Safe Medication Practices

We wish you joy, health, and happiness this holiday season!


In this week's issue:

  • Tragic error with neuromuscular blocker should prompt risk assessment by all hospitals
  • The 17th Annual CHEERS Awards: Look at How Far We've Come
    • ISMP recognized the 2014 CHEERS Award recipients for their extraordinary advances in medication safety during a dinner held at the Astor Classics Event Center Automotive & Communication Museum in Anaheim, CA. Winners included 2014 ISMP Lifetime Achievement Award recipient Janet Woodcock, MD.
  • Worth repeating... Posaconazole dosage forms not interchangeable.
    • In late 2013, a new delayed-release, enteric coated tablet was made available. This product is not to be used interchangeably with the oral suspension due to differences in the dosing of each. ISMP recently received an error report involving three adolescent patients who received overdoses of posaconazole when given the enteric coated tablets in error. 
  • Ambiguous course dosing leads to errors.
    • ISMP has received an error report involving an ambiguous intravenous immune globulin (IVIG) order that ultimately lead to an overdose of medication for the patient. The telephone order for IVIG 150 g for 5 days was interpreted as 150 g daily for 5 days but that was not the intent of the order. Similar errors have occurred when CISplatin or cyclophosphamide were ambiguously ordered as the entire course dose given over a period of days. 
  • Confusing dose pack label.
    • ISMP has received complaints about the label on methylPREDNISolone dose packs by Greenstone.  Besides being hard to read, the layout is also potentially confusing and differs from other available dose packs. 
  • The first edition of our 2015 newsletter will be published and distributed on January 15, 2015 - See you next year!

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 January 28, 2015, for Strategies to Prevent Cancer Chemotherapy Errors: Focus on Oral Agents. There has been an influx of oral chemotherapy agents available to treat cancer. Oral therapies can offer significant improvements for cancer patients, but also bring unique safety challenges. This program will explore the common causes of oral chemotherapy errors. Suggested best practices that all organizations can adopt to prevent errors will be highlighted.
    • For details, visit:
  • ISMP Fellowships
    • Interested in the ISMP Safe Medication Management Fellowship Programs? The Fellowship is a unique 12-month learning experience beginning each July that educates a healthcare practitioner in error prevention and safe medication use methods. Applications for the 2015-2016 fellowship are due March 31, 2015.
    • For more information, visit:

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