The following are excerpts from the newsletter

February 7, 2013

  • Ongoing concern about insulin pen reuse shows hospitals need to consider transitioning away from them
  • Potassium and sodium acetate injection mix-ups
    Due to the national shortage of sodium bicarbonate injection, hospitals have been dispensing sodium acetate injection as an alternate alkalinizing agent. In many hospitals, both sodium and potassium acetate solutions are stocked in the sterile products area in the pharmacy. Accidentally substituting potassium acetate in the mEq dosages commonly used for sodium acetate (e.g., 40 mEq or more) could provide a potentially fatal dose of potassium.
  • Don’t truncate, stem, or shorten drug names
    Truncating, stemming, or shortening of drug names can lead to confusion and medication errors. For example, “neo” can be confused as Neo-Synephrine or neostigmine. “Neo” can also be misheard as “levo” and be confused as Levophed, Levaquin, levodopa or levothyroxine 
  • Safety Brief: Should Clear Care be kept behind the pharmacy counter? ISMP continue to receive reports where contact lens wearers have used the solution directly in the eye or fail to soak lens for a specified period of time in the supplied special lens case. Patients experienced a severe burn sensation and excruciating pain, as well as chemical injuries to the eye. 
  • Safety Brief: Watch your Solu-MEDROLs. Due to the unavailability of methylPREDNISolone sodium succinate 40 mg vials and 125 mg vials, a hospital pharmacy began drawing up doses from SOLU-MEDROL brand 500 mg vials. Two formulations are available. The Act-O-Vial of Solu-MEDROL 500 mg has the diluent in a chamber separated from the lyophilized powder. The other Solu-MEDROL product only contains the powder in a vial. However, the cartons look nearly identical but yield different concentrations after reconstitution.
  • Safety Brief: OTC eye drops may be harmful if swallowed. Seemingly harmless over-the-counter (OTC) eye drops, such as VISINE and similar products that contain the active ingredients tetrahydrozoline, oxymetazoline, or naphazoline. These drugs can be quite dangerous if ingested.
  • Safety Brief: Nuedexta-Neulasta mix-ups. We recently received information about the potential mix-up between NUEDEXTA (dextromethorphan and quinidine) and the colony stimulating factor, NEULASTA (pegfilgrastim). 

      Special Announcements 

      • ISMP Webinars. ISMP will be holding webinars titled Reducing IV Admixture-Related Safety Risks: Implementation of the ISMP Guidelines for SAFE Preparation of Sterile Compounds on March 14, 2013 and Safety Strategies with Oral Chemotherapy, on April 23, 2013. For details about both webinars, please visit:
      • 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 Tampa, FL, on March 7-8. For details, please visit:
      •  The unSUMMIT.  Want to refine your strategies for bedside barcoding? Attend this year’s unSUMMIT for Bedside Barcoding in Orlando, FL, on April 24-26, 2013. ISMP newsletter subscribers will receive a $50 discount to the registration fee. Enter the code SMP13 at
      • Oncology assessment results. If your organization participated in the 2012 ISMP International Medication Safety Self Assessment for Oncology, you can now access the aggregate results. You should have received an email with instructions on how to access the data. For more information or questions about the comparative results, contact ISMP at: Thank you again for your participation in this project!
      • Fellowship opportunities. ISMP is now accepting applications for three 2013-2014 Fellowships. The year-long Fellowships allow the candidates to gain experience in medication error prevention initiatives. One Fellowship is tailored to a PGY4 physician resident and includes a local hospital safety rotation. The second Fellowship provides on-site experiences with both ISMP and the US Food and Drug Administration. The third Fellowship provides a candidate with an opportunity to work with interdisciplinary professionals on national and local medication safety projects. For details, please visit:
      • Applications are now being accepted for the 2013-2014 AHA-NPSF Comprehensive Patient Safety Leadership Fellowship, cosponsored by the American Hospital Association and the National Patient Safety Foundation. The Fellowship is a year-long program for clinical team and strategic leaders dedicated to improving quality and patient safety results. Fellows gain competency in advanced patient safety concepts and are able to utilize those concepts through an Action Learning Project. For details, visit:


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