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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.


octoer 8, 2009

  • ISMP QuarterWatchT
    Serious adverse drug event reports increase last quarter, 2008
  • A cautionary note for ambulatory e-Rx users!
    After sending three electronic prescriptions for the same patient to a small retail pharmacy, a prescriber immediately canceled one of medications in his computer system due to a drug-drug interaction.  Find out how this prescribing error could have still reached the patient and what physicians should know when using electronic prescribing software.
  • Safety Brief:  Tamiflu oral suspension dosing.
    The FDA recently alerted practitioners to the potential for dosing confusion with TAMIFLU (oseltamivir) oral suspension.  This issue of the newsletter provides readers with recommendations from both the FDA and ISMP regarding how to reduce dosing errors involving this product.
  • Safety Brief:  FDA and manufacturers take note!
    ISMP has received numerous reports regarding mix-ups between drug strengths that differ by a factor of 10.  Check out the newsletter to learn why these mix-ups occur and what ISMP suggests manufacturers and FDA do to make prescribing and dispensing of these products safer.
  • Safety Brief:  Lower colchicine dose effective and safer.
    The first single-ingredient oral colchine product, COLCRYS, has received FDA approval for the treatment of familial Mediterranean fever (FMF) and acute gout flares.  As a part of the application for approval, a new lower dosage schedule was found to be as effective as the previously recommended higher dose.  Read more about this clinical trial in this issue of the newsletter.
Special Announcements
  • First international fellow at ISMP.  ISMP welcomes Hind Almodaimegh, PharmD, BCPS, FCCP, as our first international medication safety fellow. Hind comes to ISMP from King Abdulaziz Medical City (KAMC), National Guards Health Affairs, Saudi Arabia, where she worked as a clinical pharmacist. She is a 2004 graduate of the University of Maryland, School of Pharmacy.  Until recently, she also served as a member of the Medication Safety Program at KAMC where she helped implement ISMP and The Joint Commission International recommendations.  Hind will serve a 1-year fellowship.

  • 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.
  • ISMP October teleconferences.

    October 15: Preventing Errors with Insulin: A Multidisciplinary Approach.  We will explore the current trends in insulin therapy, barriers to optimal therapy and safety, and common errors that occur with insulin. Error prevention strategies will be presented, including improved communication of insulin orders as well as safe preparation, storage, delivery, and administration of insulin, including the use of insulin pens.  For details on both programs, please visit: www.ismp.org/educational/teleconferences.asp.
  • ISMP Survey: Impact of Economic Crisis on Medication SafetyWe are interested in learning how today’s economy is affecting patient safety at your healthcare organization. Please take a few minutes to take our survey and submit your responses to ISMP by October 16, 2009, at www.ismp.org/survey/survey200909.asp or by fax (215-914-1492) if you don’t have access to the Internet.
  • 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!

octoer 22, 2009

  • Oral syringes: A crucial and economical risk-reduction strategy that has not been fully utilized
  • Safety Brief: False belief regarding influenza vaccines.

    ISMP recently learned of a false belief held by some hospital staff regarding the 2009-2010 seasonal influenza and H1N1 vaccines.  Find out what the misconception was and how product labeling contributed to the confusion.

  • Safety Brief: New brand-name extensions.

    Recently, several new over-the counter, brand-name extension products have been added to the market.  Learn more about the safety concerns that exist with these and other brand-name extension products.

  • Message in our mailbox: Chemotherapy wait time brochure.

    In response to our newsletter article, Ohio government plays Whack-a-Mole with pharmacist, we received an interesting and useful brochure for patients that describes why “making a dose of chemotherapy takes longer than making a milkshake.”  You can find the brochure on our consumer website at: http://www.consumermedsafety.org/tools.asp?p=resources

Special Announcements
  • Important Error Prevention Advisory: Tamiflu oral suspension shortage contributing to dosing errors.  Check out this special ISMP Medication Safety Alert! at: http://www.ismp.org/safetyalerts/20091015-Tamiflu.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.
  • 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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