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Back issues of the newsletter to January 1996 are available on CD-ROM.


November 5, 2009

  • Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions
  • Safety Brief: Seasonal flu vaccine confused with H1N1.
    ISMP recently learned of a series of mix-ups between the seasonal flu vaccine and the H1N1 vaccine.  Read more about the contributing factor that may have led to these errors and what ISMP recommends in order to help reduce the risk of error involving these products.
  • Safety Brief: Unsafe packaging of erythromycin eye ointment for newborns.
    Following the recent shortage of erythromycin ophthalmic ointment, ISMP learned of at least one compounding center that has been supplying the product in parenteral syringes.  Discover why this practice is unsafe and what ISMP recommends compounding centers and healthcare facilities who have been affected by this shortage do instead.
  • Safety Brief: Dangerous name pair.
    ISMP has been notified about the potential for mix-up between a topical ophthalmic product and a topical solution due to name similarity.  Learn which two products have the potential for mix-up, in order to determine if this situation may or may not be an issue within your own organization.
Special Announcements
  • 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.

  • ISMP Activities at the 2009 ASHP Midyear Clinical Meeting.

    • Monday, December 7-Thursday, December 10: Exhibit. ISMP will be at booth 1626 in the Venetian Hotel and Sands Expo Center exhibit hall.
    • Saturday, December 5 (7:30 a.m.-4:00 p.m.): Pre-meeting Workshop.  Using Data Effectively to Manage the Risks to Medication Safety. This 1-day interactive program presented by ISMP and the United States Pharmacopeia (USP) will help attendees learn to collect, analyze, and prioritize adverse drug event data as well as select effective risk reduction strategies based on proven safety principles.  To register, visit: www.ismp.org/educational/ismpuspworkshops.asp.
    • Tuesday, December 8 (11:30 a.m.-1:30 p.m.): Symposium.  Reducing Medication Safety Risks: Closing the Gap with the ISMP Self Assessment for Automated Dispensing Cabinets.  This program will present findings from the first ISMP Medication Safety Self Assessment for Automated Dispensing Cabinets, conducted in June 2009. Speakers will describe areas for improvement and recommendations based on the national data.  To register, visit: www.ismp.org/pressroom/symposium2009.asp.
    • Tuesday, December 8 (6:00-9:30 p.m.): 12th Annual ISMP Cheers Awards Dinner.  This gala dinner will honor patient safety leaders who have been selected to receive ISMP Cheers Awards.  To register, visit: www.ismp.org/Cheers.  Check out this year’s recipients at: http://www.ismp.org/pressroom/PR20091026.pdf.
  • 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!


November 19, 2009

  • Shakespeare was on target—don’t be a borrower or lender
  • Be clear when teaching people to use their inhalers
    Read about two instances in which a patient misunderstood how to use their inhaler properly and tips for providing clearer communication to patients regarding inhaler use.
  • Safety Brief: Inaccurate dosing if insulin withdrawn from a pen cartridge.
    Discover why the practice of withdrawing insulin from an insulin pen cartridge with a syringe can lead to incorrect dosing.
  • Safety Brief: Kids harmed from hypotonic IV fluids.
    ISMP Canada recently published a report of two pediatric deaths due to acute hyponatremia.  For more information, you can read the full ISMP Canada Safety Bulletin at the following link: http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2009-7-HospitalAcquiredAcuteHyponatremia.pdf or our August 13, 2009, newsletter article at: http://www.ismp.org/Newsletters/acutecare/articles/20090813.asp in which we reported two similar cases of acute hyponatremia in children.
  • Safety Brief: Labeling requirement to address chondrolysis.
    The FDA is advising healthcare professionals not to use any type of pump for continuous intra-articular infusion of local anesthetics due to the risk of chondrolysis (necrosis and destruction of cartilage).  In addition, the FDA is requiring that drug manufacturers and manufacturers of pumps that may be used to infuse local anesthetics, include a warning in their product labeling about this potential severe adverse effect.  More information about this FDA safety alert is available at: http://www.ismp.org/Tools/FDASafetyAlerts.asp#108.
Special Announcements
  • 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 join us on December 11, 2009, at 1:00 p.m. ET for a special, live conference call about the Fellowship program. Current and past Fellows will describe their experiences during their Fellowship as well as their post-Fellowship careers. They will also be available to answer any questions you may have about the Fellowship. To attend, please send an email to Rebecca Lamis, the current ISMP Fellow, at: ismpinfo@ismp.org

  • ISMP Activities at the 2009 ASHP Midyear Clinical Meeting.

    • Monday, December 7-Thursday, December 10: Exhibit. ISMP will be at booth 1626 in the Venetian Hotel and Sands Expo Center exhibit hall.
    • Saturday, December 5 (7:30 a.m.-4:00 p.m.): Pre-meeting Workshop.  Using Data Effectively to Manage the Risks to Medication Safety. This 1-day interactive program presented by ISMP and the United States Pharmacopeia (USP) will help attendees learn to collect, analyze, and prioritize adverse drug event data as well as select effective risk reduction strategies based on proven safety principles.  To register, visit: www.ismp.org/educational/ismpuspworkshops.asp.
    • Tuesday, December 8 (11:30 a.m.-1:30 p.m.): Symposium.  Reducing Medication Safety Risks: Closing the Gap with the ISMP Self Assessment for Automated Dispensing Cabinets.  This program will present findings from the first ISMP Medication Safety Self Assessment for Automated Dispensing Cabinets, conducted in June 2009. Speakers will describe areas for improvement and recommendations based on the national data.  To register, visit: www.ismp.org/pressroom/symposium2009.asp.
    • Tuesday, December 8 (6:00-9:30 p.m.): 12th Annual ISMP Cheers Awards Dinner.  This gala dinner will honor patient safety leaders who have been selected to receive ISMP Cheers Awards.  To register, visit: www.ismp.org/Cheers.  Check out this year’s recipients at: http://www.ismp.org/pressroom/PR20091026.pdf.
  • 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!

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