The following are excerpts from the newsletter

January 12, 2012

  • QuarterWatch(First Quarter 2011) Signals for dabigatran and metoclopramide
  • HazardAlert: Do not use an insulin pen for multiple patients! Last month, we received two reports in which nurses knowingly used the same insulin pen for multiple patients. Both nurses thought the practice was acceptable because they changed the needle between patients. A single pen device is never suitable for use with multiple patients due to the risk of cross contamination and transmission of blood-borne diseases. To reduce the risk of cross contamination, insulin pens used in inpatient settings should be assigned to individual patients and labeled accordingly.
  • Safety Brief: Study provides evidence base for ISMP’s ambulatory care high-alert drug list. More than two-thirds of the drugs tied to hospitalization after emergency department (ED) visits for adverse drug events in older adults appear on our List of High-Alert Medications in Community/Ambulatory Healthcare. These findings, from a study published in November 2011 by Budnitz et al. in the New England Journal of Medicine were derived from adverse event data in the Centers for Disease Control and Prevention’s National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project (2007-2009).
  • Safety Brief: Chemotherapy mix-up between eribulin and epirubicin. An order for the antimicrotubular antineoplastic agent “eribulin” (eribulin mesylate, HALAVEN) was misinterpreted by a pharmacist and entered into the computer system as epirubicin, an anthracycline antineoplastic agent. Fortunately, the error was detected by a nurse when comparing the pharmacy label to the original order, and the patient did not receive the wrong drug.
  • Safety Brief: Pharmacy student discovers overdose in product labeling. Sal Rivas, a 3rd year pharmacy student at Roseman University of Health Sciences College of Pharmacy in Henderson, NV contacted us about a website dosing error for LITTLE NOSES DECONGESTANT NOSE DROPS, which contains phenylephrine HCl 0.125%. During a website redesign project, the company, Little Remedies, inadvertently listed the product dose as 1 mL for 2- to 6- year-old children. The correct dose should have been listed as 2 to 3 drops in each nostril.

Special Announcements...

  • ISMP Fellowships
    • ISMP is now accepting applications for its 2012-2013 ISMP Safe Medication Management Fellowship and the FDA/ISMP Safe Medication Management Fellowship. These 1-year learning opportunities offer practitioners interested in patient safety a challenging and rewarding experience that will enhance their career growth. The application deadline is March 30. For more information and a copy of the application, visit:
    • For the first time, ISMP is also offering a 1-year physician fellowship in patient and medication safety for an eligible PGY4 medical resident. This Stephen R. Lewis, MD Fellowship is a unique program that will be operated jointly by ISMP and Abington Memorial Hospital in nearby Abington, PA, under the direction of the physician Chief of Patient Safety.
    • The application deadline for the physician fellowship is also March 30. For more information please email and express your desire to learn more about the program.
  • The unSUMMIT
    Want to refine your strategies for bedside barcoding? Attend this year’s unSUMMIT for Bedside Barcoding in Anaheim, CA, on May 2-4, 2012. ISMP newsletter subscribers will receive a $50 discount applied to the registration fee by entering the code ISM12 at:
  • 1-week “rotation” at ISMP
    We have room for just a few more participants in our weeklong ISMP Practitioner in Residence Program on February 13-17, 2012, at ISMP’s office in suburban Philadelphia, PA. The program provides healthcare professionals with medication safety oversight in their organization with a unique opportunity to work
    closely with ISMP staff. For details, visit:
  • ISMP webinar
    Join ISMP on February 15 for our webinar on Challenges in Oncology Medication Safety: Identifying Risk and Opportunity. Risks are often present when providing oncology services due to the complexity of chemotherapy regimens, variability in dosing, the toxic nature of the drugs, and the specialty staff required. Join interdisciplinary speakers as they address these unique challenges and discuss the release of the free 2012 International ISMP Medication Safety Self Assessment for Oncology. For details, visit:

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