The following are excerpts from the newsletter

November 17, 2011

  • Conservative prescribing needed to improve medication safety
  • Safety Brief: Infant acetaminophen shipped in new concentration. The new 160 mg/5 mL infant acetaminophen concentration has been arriving in hospitals, although manufacturers may not be providing notification about the change. For more information regarding the change in strength of pediatric liquid acetaminophen, visit:
  • Safety Brief: FentaNYL shortage-seems like 2001 all over again! During the last fentaNYL shortage in 2001, we reported about several serious dosing errors when SUFentanil was used as a substitute for fentaNYL. There is every reason to believe that similar errors are possible as a result of the current shortage and situations where people using SUFentanil instead of fentaNYL are not familiar with the differences between these drugs.
  • Safety Brief: Label needs improvement. The label on vials of the new antibiotic TEFLARO (ceftaroline fosamil) is difficult to read. Both the dosage strength and generic name on 400 mg and 600 mg vials are printed in a small font. The FDA and manufacturer have been contacted.

Special Announcements...

  • ISMP symposium. Improper preparation of sterile IV products has led to patient deaths. 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 December 6 (11:30 a.m. to 1:30 p.m.). Presenters will discuss their experiences with DoseEdge-Pharmacy Workflow Manager (Baxa), ScriptPro Telepharmacy, and i.v.SOFT Assist (Health Robotics). To register, please 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. To register, please visit:

ISMP webinars:

  • 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" HYDROmorphone events and to hear about safety strategies that hospitals are implementing to prevent HYDROmorphone-related events.
  • On January 12 (2012), ISMP will present Medication Safety Officers: A Necessary Practitioner in Today’s Healthcare Environment. The role of the medication safety officer has fast become an essential position in many hospitals. Hear firsthand from two medication safety officers about the pivotal role they play in their organization, lesson’ s learned from their experiences, the unique approaches they’ve used, and three things everyone working in this field should know. For details on both webinars, please visit:

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