The following are excerpts from the newsletter

November 3, 2011

  • Ingestion or aspiration of foreign objects or toxic substances is not just a safety concern with children
  • President Obama issues executive order to respond to drug shortage
    Take ISMP’s survey on harm caused by drug shortage to maintain momentum
    President Obama issued an executive order this week, taking steps to help resolve the nation’s drug shortage crisis. Check out this week’s newsletter to learn more about this issue. In addition, ISMP is conducting a nationwide survey ( to learn about patient harm that has occurred as a result of the ongoing drug shortage crisis. We are asking a representative from every healthcare facility to participate in this important survey if any of your patients have been harmed in any way by the drug shortage within the past 5 years!
  • Oral KCl overdose fatal. A nursing home resident died from cardiac arrest after receiving a 10-fold overdose of oral potassium chloride because an order for 8 mEq was misinterpreted by several facility staff members as 80 mEq. Learn more about how this error occurred and the strategies that can be implemented to prevent this from happening.
  • ISMP holds IV admixture safety summit. Almost 60 representatives from industry, regulatory affairs, medication safety, healthcare information technology, pharmacists, pharmacy technicians, nurses, and consumers met in the Philadelphia area on October 25-26, 2011 to develop guidelines to promote the safety of IV admixture programs operated by hospitals as well as outside vendors. Draft guidelines are being developed by the group and will be available for public comment in early 2012.
  • <797> survey results available. For results from a survey previously mentioned in this newsletter to evaluate current sterile compounding practices in the US related to USP <797> compliance, please visit:
  • One teaspoonful is 10 mL, right? The manufacturer of Zarbee’s All-Natural Children’s Cough Syrup incorrectly lists “1 Tsp” as “10 mL” on its label. We have contacted Zarbee’s as well as FDA.

Special Announcements...

  • ISMP symposium. Improper preparation of sterile IV products has led to patient deaths and gained increasing attention as a public health issue. If you would like to learn how barcoding, digital imaging technology, and improved staff training reduce the risk of IV compounding errors, attend ISMP’s symposium at the ASHP Midyear Clinical Meeting on Tuesday, December 6. To register, visit:
  • Cheers registration. Join us for this year's ISMP Cheers Awards reception and dinner as we honor our award winners and celebrate another year of superlative work advancing our shared goal of medication error prevention. This year’s gala will be held at the New Orleans Board of Trade on December 6, in conjunction with the ASHP Midyear Clinical Meeting. To register, please visit:
  • DVD sale. For a limited time, we are offering a series of medication safety DVDs marked down from $125 to $50. The four featured DVDs include: Medical Leaders in Patient Safety, Patient Safety Requires a Team Effort, Building System Safeguards for the Safe Use of High-Alert Medications, and Patients Play a Vital Role in Patient Safety. For details, visit:

ISMP webinars:

  • On November 17, ISMP will present When Caring Hurts: Understanding the Second Victim Experience. When patients suffer unexpected clinical events, healthcare clinicians are also at risk of suffering as a result of the unanticipated outcome and become "second victims." Suffering practitioners feel as though they have failed the patient and frequently second guess their clinical skills, knowledge base, and career choice. Join Susan Scott, MSN, a patient safety officer who has conducted studies on this topic, as she describes the second victim experience and interventional strategies, including use of a specialized rapid-response team.
  • On December 14, ISMP will present HYDROmorphone: Taking Aim at Events Under the Radar - Regional Initiatives that Show Improvement. HYDROmorphone continues to be associated with patient harm. Some organizations have begun to recognize this risk, while others may not be aware of the number of adverse events associated with this drug. Join us to learn how to uncover these "hidden" events and to hear about safety strategies that several hospitals are implementing to prevent HYDROmorphone-related events.

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