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The full version of the newsletter is available by subscription
Back issues of the newsletter to January 1996 are available on CD-ROM.


december 3, 2009

  • Eric Cropp weighs in on the error that sent him to prison
  • Safety Brief: Cetacaine bottles with Luer connector.
    While CETACAINE liquid (benzocaine 14%, butamben 2%, tetracaine hydrochloride 2%) continues to be available in spray and gel forms, the widely used local anesthetic is now also available in a bottle with a dispenser cap that is compatible with any Luerlock syringe.  Learn what ISMP recommends that healthcare facilities and the manufacturer do in order to reduce the potential for error with this product.
  • Safety Brief: Safer connectors in the UK.
    The National Patient Safety Agency (NPSA) has just published an alert to ensure that all spinal bolus doses and lumbar puncture samples will be performed using syringes, needles, and other devices that will not connect with IV Luer connectors.  In addition, all epidural, and regional infusions and boluses must be delivered with devices that will not connect with IV Luer connectors or IV infusion spikes.  To learn more about this alert, check out the National Reporting and Learning Service’s (NRLS) website at: http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=65259.
  • Safety Brief: ISMP supports ASMSO.
    ISMP has signed an agreement with the American Society of Medication Safety Officers (ASMSO) (http://asmso.org) to provide organization management services to the group.  As of December 1, 2009, ASMSO may be contacted through ISMP at 200 Lakeside Drive, Suite 200, Horsham, PA 19044.  The telephone number remains the same as before: 508-499-3043.
Special Announcements
  • ISMP webinar. Please join us on January 14, 2010, for the first ISMP webinar of the year, titled The “Lean” Approach to Improving Medication Safety. Nicole MacLaughlin, PharmD, Pediatric Medication Safety Officer at Johns Hopkins Hospital, will describe how Lean principles—a method created by Toyota that focuses on eliminating process waste and creating value—have been used to prevent errors and improve safety.  Considering today’s economy, this is one webinar you can’t afford to miss! For details, please visit: www.ismp.org/educational/webinars/default.asp.

  • ISMP Fellowship.  ISMP is now accepting applications for its 2010-2011 Safe Medication Management Fellowship.  This 1-year learning opportunity, funded by Cardinal Health Foundation, offers practitioners interested in patient safety a challenging and rewarding experience that will enhance their career growth. The application deadline for the 2010-2011 fellowship is January 31; for more information and a copy of the application, visit: www.ismp.org/profdevelopment/managementfellowship.asp.

  • Please help support ISMP.  We invite you to make a tax-deductible donation to ISMP to help us achieve our goals in 2010.  Your gift, small or large, will further our lifesaving work and enhance our capacity to help you protect your patients from medication errors. We thank you for making an investment in our future. Together we are Actively caring for safety: One team, one goal, the power of many.  To make a donation, please visit our website at: http://www.ismp.org/about/support.asp.
  • Free Safety Videos. The latest medication related FDA Patient Safety News videos (created in cooperation with ISMP) are available for free viewing or downloading on the ISMP website (www.ismp.org/Tools/fdavideos.asp). Check them out!

december 17, 2009

  • Santa checks his list twice. Shouldn't we?
  • Safety Brief: New alert system.
    ASHP and ISMP recently announced that the two organizations have partnered to develop the National Alert Network for Serious Medication Errors (NAN), which will be activated only when the most dangerous types of errors or conditions are identified.  The alerts will be disseminated through ISMP’s normal channels of communication in addition to ASHP’s network of healthcare practitioners.  Recipients across the nation can use the recommendations provided in the alerts to take immediate action in order to ensure the error is not repeated at their facilities.
  • Safety Brief: Avoid more than one of these.
    ISMP has been notified of yet another potential for mix-up between various eye drops due to the FDA- and American Academy of Ophthalmology-sanctioned color-coding system that is based on pharmacologic class.  Check out this issue of the newsletter to learn if this potential mix-up could result in error at your organization.
  • Safety Brief: Lithium safety alert.
    The National Patient Safety Agency (NPSA) in England and Wales has released an alert requesting that all healthcare organizations, where lithium therapy is initiated, prescribed, dispensed, and monitored, comply with safe treatment practices established by the National Health Service.  More information about this alert can be found at the following link: http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=65426.
Special Announcements
  • The next issue of the newsletter will be published on January 14, 2010...See you next year!

  • Medication Safety Fellowships. FDA and ISMP are now accepting applications for the 2010-2011 FDA/ISMP Safe Medication Management Fellowship. The application deadline is
    February 26; for information, visit www.ismp.org/profdevelopment/fdaismpfellowship.asp. Separately, ISMP is also accepting applications for the ISMP Safe Medication Management Fellowship, sponsored by Cardinal Health Foundation. The application deadline is January 31; for information, visit www.ismp.org/profdevelopment/managementfellowship.asp. Both opportunities offer practitioners interested in patient safety a challenging and rewarding experience to enhance their career growth.

  • ISMP employment. ISMP is seeking a pharmacist (PharmD or Master’s degree) or nurse (Master’s degree) with at least 5 years clinical and managerial experience for a full-time position in Horsham, PA, in our consulting division. For consideration or more information, visit www.ismp.org/jobline/mse.asp and send your resume and salary requirements to ismpinfo@ismp.org, or call 215-947-7797.

  • ISMP webinar. Please join us on January 14, 2010, for the first ISMP webinar of the year, titled The “Lean” Approach to Improving Medication Safety. Nicole MacLaughlin, PharmD, Pediatric Medication Safety Officer at Johns Hopkins Hospital, will describe how Lean principles—a method created by Toyota that focuses on eliminating process waste and creating value—have been used to prevent errors and improve safety.  Considering today’s economy, this is one webinar you can’t afford to miss! For details, please visit: www.ismp.org/educational/webinars/default.asp.

  • 12th Annual ISMP Cheers Awards. For 12 years, ISMP has honored individuals and organizations whose innovation and tireless dedication have helped make significant achievements in preventing medication errors and saving patient lives. This year’s winners were recognized at an awards dinner held last week in Las Vegas, NV. Please join us in congratulating the following award recipients, who serve as role models for what can be achieved in the field of medication safety. Check out this year’s recipients at: http://www.ismp.org/pressroom/PR20091026.pdf.


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