The following are excerpts from the newsletter

April 4, 2013

  • Your high-alert medication list—Relatively useless without associated risk-reduction strategies
    Safety Brief: Don’t become opioid (misinformation) tolerant. Results of an opioid knowledge assessment of more than 1,700 prescribers, pharmacists, and nurses published by the Pennsylvania Patient Safety Authority has uncovered the depth of misinformation surrounding the safe use of opioid medications (
  • Safety Brief: Identifying cloNIDine patch strengths. Currently, the name and strength of the drug does not appear on CATAPRES (cloNIDine) transdermal patches once they have been applied to patients. What appears is a code that is embossed on each patch that can be used to identify the strength.
  • Safety Brief: Nalbuphine-naloxone mixups. A patient safety officer reported that her hospital experienced two incidents in which patients received nalbuphine instead of naloxone. Several strategies may help mitigate inadvertent sections of the wrong drug.
  • WorthRepeating...Mix-ups between risperiDONE and rOPINIRole. Last month, we received yet another report of a mix-up between risperiDONE (RISPERDAL) and rOPINIRole (REQUIP). As in earlier cases, both products were from the same manufacturer and in the same shaped bottle with similar label printing.
  • ISMP webinars. ISMP will be holding webinars titled Safety Strategies with Oral Chemotherapy on April 23, 2013 and Unsafe Injection Practices are Placing Patients at Risk—Take Action Now on May 9, 2013.  For details about both webinars, please visit:

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