The following are excerpts from the newsletter

December 1, 2011

  • Look out for Lugol’s...

    Error-prevention strategies for this strong iodine solution

  • CMS revises its policy on the "30-minute rule"
    The Centers for Medicare & Medicaid Services (CMS) updated its guidance on medication administration in hospitals to reflect current standards of practice related to the timely administration of medications on November 18, 2011. Check out this week’s newsletter to learn more about the updated CMS guidance. 

  • More on infants' acetaminophen concentration confusion.
    In our last issue, we mentioned that all liquid acetaminophen products for children under the age of 12 are now being manufactured and distributed in the 160 mg/5 mL strength (32 mg/mL), including infants’ formulations that were formerly 80 mg/0.8 mL (100 mg/mL). Check out this week’s newsletter to find out what healthcare practitioners and parents should do to prevent medication errors related to this change.
  • Hard to swallow.
    The lead article in our November 3, 2011, newsletter discussed the issue of leaving foreign objects or toxic substances at the patient’s bedside. In one instance, a patient developed breathing difficulties due to an aspirated syringe cap that he might have confused as a drug tablet. Please view this week’s newsletter to learn about another similar event that was recently reported to ISMP.

  • ISMP issues statement on use of metric measurements
    In a board-approved statement issued last month, ISMP called for prescribers, pharmacists and other healthcare professionals, as well as pharmacy computer system and e-prescribing system vendors, to only use metric measurements in prescription directions. After careful deliberation, ISMP issued this statement to better protect patients from harmful errors. To learn more about recommended actions involving use of metric measurements, please see this week’s newsletter.

Special Announcements...

  • ISMP symposium.
    Learn how barcoding, digital imaging technology, and improved staff training can reduce the risk of IV compounding errors by attending ISMP’s symposium at the ASHP Midyear Clinical Meeting on December 6 (11:30 a.m. to 1:30 p.m.). To register, visit:
  • ISMP webinar.
    January 12-Medication Safety Officers: A Necessary Practitioner in Today's Healthcare Environment. For details and to register, visit:

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