November 2014

In this month’s issue:

  • Raising the index of suspicion: Red flags that represent credible threats to resident safety. Disruptive behaviors, intimidation in the workplace, and a culture of disrespect among healthcare professionals have repeatedly surfaced as a significant barrier to resident safety and cause of medication errors. This article discusses a less obvious and no less dangerous form of subtle intimidation called "deferrence to expertise", along with flags that suggest this type of intimidation is occurring and how to counteract it to protect the resident.
  • SafetyWires: Discusses three recently reported errors in long-term care facilities caused by failing to communicate a hold order that resulted in hospitalization of the resident; the use of an inappropriate numeric description in a fentaNYL transdermal patch order that resulted in an error; and potential dose confusion with SPIRIVA.
  • Delay in introducing new feeding tube connectors. Discusses a delay in the new ENFit enteral feeding administration set and transition connector previously discussed in the September 2014 issue.
  • HYDROcodone combination products now Schedule II.  Discusses a recent DEA change in the classification of HYDROcodone combination products (e.g., NORCO) from Schedule III to Schedule II.
  • Report Medication Errors to ISMP at 

    Report medication errors to ISMP. Share your medication safety stories and error reports in confidence by calling ISMP 1-800-FAILSAF(E), via our website (, or by email ( Reporter identity and location remain strictly confidential and are never published. Anonymous reports are also accepted. 

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