The following are excerpts from the newsletter

March 7, 2013

  • Survey results: Community liaison programs to decrease hospital readmissions
  • Safety Brief: Peculiar packaging for Priftin. PRIFTIN has some peculiar packaging that may be problematic when the drug is used in the hospital.  Confusion arises when evaluating the total dose and expiration date within a sleeve of the medication.
  • Safety Brief: QC for barcodes. We wish manufacturers would do a better job with quality control for barcodes placed on packaging.  These issues can interrupt the workflow of healthcare practitioners.
  • Safety Brief: Confusion between two HER2-targeted monoclonal antibodies. Problems may arise with KADCYLA (adotrastuzumab emtansine) and HERCEPTIN (trastuzumab).  Although the dosing of these medications is different, there is the potential of errors occurring.
  • Safety Brief: “IT” abbreviation misunderstood. Depending on the context of the abbreviation, “IT” can refer to a multitude of terms.  Ambiguity of this 2-letter abbreviation can lead to medication errors.
  • Last chance to apply for an ISMP Fellowship. ISMP is accepting applications until March 30, 2013 for three 2013-2014 Fellowships.  The year-long Fellowships allow the candidates to gain experience in medication error prevention initiatives.  One Fellowship provides a candidate with an opportunity to work with interdisciplinary professionals on national and local medication safety projects.  The second Fellowship is tailored to a PGY4 physician resident and includes a local hospital safety rotation.  The third Fellowship provides on-site experiences with both ISMP and the US Food and Drug Administration.  For details, please visit:
  • ISMP Medication Safety Alert! Readership Survey. It has been almost a decade since we last surveyed our newsletter readers regarding satisfaction and effectiveness of the ISMP Medication Safety Alert!  There is an important survey at  Please submit your responses by April 12, 2013.
  • 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:

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