The following are excerpts from the newsletter

January 26, 2012

  • Entire newsletter
  • Don't let the "tobacco stain" on pharmacies that sell cigarettes be a barrier to advanced pharmacy practice (Report to Surgeon General calls for recognition and compensation of pharmacists)
  • Does the CMS standard to store medications according to manufacturer's directions impact drug shortages and increase waste?   Please take our survey and let us know about your experiences. A healthcare organization’s ability to manage drug shortages and reduce waste may be compromised by the way the Centers for Medicare & Medicaid Services (CMS) and Joint Commission surveyors apply statements in CMS interpretive guidelines ( related to stability, expiration dating, and storage of parenteral medications before and after they are manipulated to prepare injections. On the one hand, the interpretive guidelines associated with CMS standard §482.25(a) state, in part, that accepted professional principles must be followed as well as standards or recommendations promoted by nationally recognized organizations like FDA, the National Institutes of Health, the American Society of Health- System Pharmacists, and others. In conflict with these statements, the interpretive guidelines also state, “Drugs and biological are stored in accordance with manufacturer’s directions and State and Federal requirements.” Strict adherence to this means that professional standards or official compendia recommendations for stability information do not apply. We would like to hear from pharmacists and other healthcare practitioners about their experiences with this issue. We urge hospital pharmacists to complete a short ISMP survey at so we can learn more about any unintended consequences of the CMS directive. If change is warranted, we plan to further pursue the issue with CMS officials.
  • Safety Brief: Allergy listing in electronic database. During an office visit, a patient reported that she had seasonal allergies. The nurse typed ‘seasonal’ into the allergy database without realizing that the system converted it to the birth control pill “SEASONALE,” (levonorgestrel ethinyl estradiol). Because electronic health records (EHR) may share a common allergy database between drug prescribing and dispensing systems, you should investigate how your EHR identifies and incorporates allergies that aren’t drug related.
  • Safety Brief: OR nurses: “Stop using multidose vials.” The Association of periOperative Registered Nurses (AORN) recently released a set of recommended practices for medication safety in the association’s 2012 edition of Perioperative Standards and Recommended Practices ( The standards include a recommendation to collaborate with pharmacists to procure and store single-dose vials rather than multidose vials due to evidence indicating that multidose vials pose a risk of cross contamination as well as administering too much medication.
  • Safety Brief: New OR medication safety video available. A new 18-minute video about medication safety in the operating room (OR) is now available from the Anesthesia Patient Safety Foundation (APSF). The video, Medication Safety in the Operating Room: Time for a New Paradigm, is intended for anesthesia professionals but anyone responsible for care of patients in the OR can benefit from a better understanding of safe medication use in this unique environment. A complimentary copy of the DVD is available at:
  • Safety Brief: QuarterWatch™ report link. In the QuarterWatcharticle in our last issue, we inadvertently left out a link to the full report on our website. The report can be accessed at:

Special Announcements:

  • Last chance to participate! ISMP is keeping track of error reports where harm occurred due to the drug shortage crisis. If the drug shortage has contributed to harmful outcomes for any of your patients, we urge you to make a difference by participating in the ISMP survey at: before February 29. Your participation may contribute to much needed reform at a national level!

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