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June 3, 2010

  • Failure to set a volume limit for a magnesium bolus dose leads to harm
  • Painful eye injuries with improper use of Clear Care solution

    When used improperly, Clear Care contact lens cleaning solution can cause painful eye injuries.  Learn why the design and placement of the warnings on the bottle and carton may need to be improved in order to reduce the risk of these errors.

  • Safety Brief: Questionable safety with continuous inhalation albuterol infusion set-up.

    Read about an error that occurred as a result of the practice of adding albuterol inhalation solution to an IV bag
    intended for continuous inhalation administration.

  • Safety Brief: Hello, anyone out there?

    ISMP recently learned of an over-the-counter product that had been using an obscure and confusing method for listing its expiration date.

  • Safety Brief: Label improvement needed.

    ISMP was notified of a product in which the dosage strength on the front of the vial cannot be easily read due to font size.

Special Announcements

  • ISMP webinar. Join us on June 30 for a special webinar that taps into the heart of ISMP staff’s expertise in medication safety, Risks Encountered during ISMP Hospital Safety Assessments. ISMP’s interdisciplinary consulting team has been invited into hundreds of hospitals to assess risk and provide individually tailored support for medication safety improvements. Join the consulting team as they discuss common but serious system-based risks encountered in many hospitals, and innovative best practice recommendations. To register, please visit:

  • ASHRM webinar. To celebrate Healthcare Risk Management Week (June 14-18), the American Society for Healthcare Risk Management (ASHRM) will be hosting a webinar on June 16 entitled Insidious Intimidation: The Underestimated Threat to Patient Safety. In honor of ASHRM’s 30-year anniversary, the webinar will be provided to ASHRM members for just $30 per site. For details, visit:

  • ISMP-A.S.P.E.N. error-reporting project. ISMP and A.S.P.E.N. (American Society for Parenteral and Enteral Nutrition) are working collaboratively to educate clinicians about the benefits of reporting errors involving nutrition support therapy and associated devices. Our goals are to: learn about the underlying causes of these errors; publish and present our findings; develop educational materials and strategies to reduce errors with nutrition therapy; and to foster national initiatives that address risk reduction for nutrition support. To report errors involving nutrition support, please visit: For more information about the project, visit:


june 17, 2010

  • ISMP QuarterWatch (Quarter 4 and 2009 totals) - Reported patient deaths increased by 14% in 2009

  • CMS 30-minute rule may result in unintended consequences

    The Centers for Medicare & Medicaid Services (CMS) regulation [§482.23(c)(1)], that requires medications to be administered within 30 minutes before or 30 minutes after their scheduled times, may sometimes cause nurses to drift into unsafe work habits. Read more about ISMP’s concerns with this CMS rule in this week’s issue.

  • Safety Brief: EPINEPHrine shortage warning from NAN.

    A National Alert Network (NAN) message is being issued by the American Society of Health-System Pharmacists (ASHP) and ISMP regarding the EPINEPHrine 1 mg/10 mL (0.1 mg/mL) prefilled syringe shortage. Look for the alert in your email, or visit: or
  • Safety Brief: Inhaled medication dosing times.

    While CMS regulations require medication administration within 30 minutes before or after a scheduled dose, the American Association for Respiratory Care (AARC) has a position statement on inhaled medication dosing times that differs from the CMS 30-minute rule. For more information regarding this position statement, check out this week’s issue.
  • Message in our mailbox: Genetic testing for warfarin sensitivity.

    ISMP received a comment from a pharmacist regarding our recent In the News feature about pharmacogenetic-driven warfarin dosing (Genetic testing and warfarin dosing. March 25, 2010). Read more in this week’s issue.

Special Announcements

  • ISMP June webinar. Join ISMP’s interdisciplinary consulting team on June 30 for a special webinar, Risks Encountered during ISMP Hospital Safety Assessments. To register, visit:
  • ISMP July webinar. On July 22, ISMP will present its annual The Joint Commission (TJC) Medication Management Update (2010). Our speaker, Darryl Rich, PharmD, a surveyor for TJC, will discuss new and revised medication standards for hospitals and tips to help meet the intent of the standards. For details, visit:
  • ISMP Cheers Awards! Nominations for this year’s ISMP Cheers Awards are now being accepted through August 27, 2010. The Cheers Awards honor individuals, organizations, companies, and agencies that have set a superlative standard of excellence in the prevention of medication errors during the previous year. For details, please visit:


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