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The following are excerpts from the newsletter

april 8, 2010

  • Latest heparin fatality speaks loudly—What have you done to stop the bleeding?
  • Safety Brief: Confusion between organ preservation solutions and IV containers.
    Discover how organ preservation solutions may be mistaken for IV infusion containers and what steps your organization can take to reduce the risk of mix-up.

  • Safety Brief: Enteral nutrition safety.
    The American Society for Parenteral and Enteral Nutrition, in partnership with Nestlé Nutrition, has launched a campaign to help prevent enteral misconnections and improve enteral nutrition safety. For additional information, please visit:

  • Safety Brief: LQ? LAR? DSC? Drug name suffixes and their meanings.
    As drug name suffixes can contribute to confusion and medication errors, ISMP has created a document which includes a list of drugs whose names contain a suffix, along with meanings of the suffix (

  • ISMP errata. In our March 11, 2010 SafetyBrief, Root cause analysis published, we mentioned that the analysis of a fatal error conducted by ISMP appeared in the March 2010 issue of The Joint Commission Journal on Quality and Patient Safety. Actually, the article is in the April 2010 issue. We thank our readers for alerting us to this mistake. We have since learned that full text of the article is available free at:

Special Announcements

  • New ISMP webinar series.
    Join ISMP for an ongoing series of ISMP Action Agenda webinars designed exclusively for pharmacy and therapeutics or safety committees to bring your medication safety review process to life. The first webinar on April 22 is offered at a significant discount so you can see how these sessions, led by ISMP President Michael R. Cohen, can help advance your medication safety agenda and help you meet several Joint Commission standards. For details and to register, visit:

  • Free webinar series for nurses! Based on the 2009 Nursing Leadership Congress proceedings, a series of free webinars have been planned on different topics on May 20 (healthcare policy update), June 23 (designing a patient safety plan), and August 26 (connecting disparate clinical data). For details, visit:

april 22, 2010

  • Building Patient Safety Skills: Common Pitfalls When Conducting a Root Cause Analysis
  • Safety Brief: Distribute instructions for oral dispenser.
    The oral dispenser that accompanies morphine sulfate oral solution 100 mg/5 mL may be causing confusion regarding how to measure a dose.  Find out how the design of the dispenser may be contributing to errors.
  • Safety Brief: Seasonal vaccine “H1N1” is not 2009 pandemic strain.
    Learn about a mix-up involving the seasonal influenza vaccine and the H1N1 vaccine.
  • Safety Brief: Propofol container labels need revision.
    ISMP recently learned of a dosing error involving propofol.  Discover how the package labeling contributed to the error.
  • Safety Brief: Same name, different drug.
    ISMP previously noted a problem with some US products having the same exact brand names as foreign drug products with completely different ingredients.  Recently, ISMP learned of yet another pair of products with the same brand name but different ingredients.  Learn more about the affected products and how patients traveling overseas can reduce their risk of receiving the wrong medication.

Special Announcements

  • ASHP Summer Meeting. Medication safety officers and leaders who direct quality improvement activities can benefit from attending the ASHP Summer Meeting this June in Tampa, FL, which includes special sessions devoted to medication safety. Find details and more at:

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