The following are excerpts from the newsletter

February 9, 2012

  • Results of ISMP survey on High-Alert Medications: Differences between nursing, pharmacy, and risk/quality/safety perspectives
  • Safety Brief: Names too close for comfort. We received a report about a mixup between etravirine (INTELENCE) and ethaverine (ETHATAB; ETHAVEX). Both are listed in some computer system databases, and both come in 100 mg tablets. A pharmacist reported that ethaverine was ordered on two occasions when etravirine was intended. This sort of error supports the need to include a medication’s purpose as part of the order entry process.
  • Safety Brief: Rapaflo and Rapamune confusion. A mix-up has been reported between RAPAFLO (silodosin), and RAPAMUNE (sirolimus). The order for Rapaflo was legible and read: “Rapaflo 8 mg daily PO (silodosin capsule).” However, Rapaflo was not among the computer inventory listings or drug dictionary because it was a non-formulary medication. Instead, a pharmacist accidentally selected Rapamune (sirolimus) and scheduled 8 mg to be given PO daily (as 8 x 1 mg capsules).
  • Safety Brief: New Broselow tape available. A new Broselow tape (dated 2011 Edition A) is available. The tape has revised zones based on new national data on length-weight relationships in children, making these tapes more accurate. Please be sure to update your tapes. For more information, visit:
  • Safety Brief: Medical equipment, not a toy. Never allow hospitalized children to play with IV syringes. A school-age child was given a syringe for play. The next morning the child pressed the call bell because of chest pain and a cough. She informed the nurse that she had connected the syringe to her central IV line and had pushed in air.
  • Safety Brief: Name that patch. At a transdermal system workshop held last September, FDA’s Gerald DalPan publicly stated that FDA recommends that the drug name (brand and generic), total drug content, and drug delivery rate be clearly marked on the patch, and that such markings be visible throughout the duration of wear ( Hopefully, companies will be following through since not all provide this information on the patches, and we continue to hear about these errors.

Special Announcements:

  • A Unique 2--day program.. Attend ISMP’s Medication Safety INTENSIVE workshop, an interactive program that provides a basis for effective approaches to medication safety. Sharpen your risk assessment and event investigation skills, and learn more about Just Culture, Lean Six Sigma, high-leverage error-reduction strategies, and more. The workshop will be held in Orlando, FL, on March 8-9. For details, visit:
  • ISMP webinar. Join ISMP on March 6 for a webinar on Reducing Hospital Readmissions Through Medication Use Optimization. Beginning in 2013, the Centers for Medicare & Medicaid Services (CMS) will be withholding reimbursement for hospital readmissions. Learn what medications are associated with hospital readmissions, as two pharmacists discuss medication-related readmission reduction programs implemented at their institutions and their impact on readmission rates. For details, visit:
  • ISMP Fellowships. ISMP is now accepting applications for its 2012-2013:

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