August 2015

In this month’s issue:

  •  Safe disposal of controlled substances - A new long-term care approach
  • A report on warfarin deaths and injuries in nursing homes
  • Zolpidem and unsafe use
  • NAN ALERT: Use dosing cups with mL markings only
  • SAFETYwires 
      • Ketoacidosis with new oral diabetes drugs.
      • Unexpected painful breath

Special announcements:

  • 18th Annual ISMP Cheers Awards
    • Submit nominations by September 11th for individuals and organizations that have set a standard of excellence in the prevention of medication errors in the previous 12 months. Join us at The Chicory in New Orleans on December 8th to celebrate the winners!  See:
  • NPSF issues RCA guidelines
    • The National Patient Safety Foundation just released new guidelines to help organizations improve the way they investigate errors, adverse events, and close calls RCA2: Improving Root Cause Analyses and Actions to Prevent HarmFor a copy, go to


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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