July 2014

In this month’s issue:

  • We have a new look!  (the PDF version of our newsletter has a fresh new look)
  • U-500 Insulin Safety Concerns Mount.  Although uncommonly seen in the long-term care (LTC) facilities at present, U-500 insulin use is expected to grow in this setting.  The use of this different strength of insulin has cause a unique set of medication errors.  This article discusses some of those errors and ways to prevent them.
  • Unusual syringe design for oral morphine cause errors. Discusses the design of an oral syringe for morphine oral solution where the tip is pointed rather than flat, causing dosing errors.  A description of how to read the syringe markings accurately is presented.
  • Auvi-Q injection Ticking Sound. The AUVI-Q auto-injector (EPINEPhrine injection) uses digital voice instructions to “talk” people through the injection process. If not used properly, the device makes a loud “ticking” sound that has caused concern.  The article discusses the cause of the “ticking” sound and what to do in response to it.
  • SafetyWires: Discusses medication safety issues with multiple MARs.?
  • Special announcement...
    • ISMP's Annual Fund
      • The healthcare community would be very different without ISMP's existence over the last 20 years. (For a list of ISMP's many important contributions to safety, please visit: We depend on the caring individuals and organizations that passionately support our work. Your charitable donation to the Annual Fund will help keep ISMP an important part of the fight against preventable medication errors.

Report medication errors to ISMP. Share your medication safety stories and error reports in confidence by calling ISMP 1-800-FAILSAF(E), via our website (, or by email ( Reporter identity and location remain strictly confidential and are never published. Anonymous reports are also accepted. 

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