The following are excerpts from the newsletter

January 30, 2014

In this week's issue:

  • A mislabeling event with batch drugs: The unintended consequences of practice changes
  • Regarding the current IV solution shortage affecting US hospitals
  • Morse code?
    • Recently, a pharmacist brought to our attention a blue and orange prescription capsule that did not have an imprinted alphanumeric code. Without a company name or alphanumeric code it is hard to see how anyone could easily identify this item.
  • More barcodes than needed.
    • There are a number of medications with two or more barcodes printed on the package. The presence of multiple barcodes is confusing to staff and has resulted in practitioners overriding the barcode system. 
  • Florinef vs. Floranex.
    • Recently a verbal order for FLORANEX (lactobacillus) was entered as FLORINEF (fludrocortisone). These names sound almost identical when spoken and can also be confused in print or when handwritten. 
  • Medication Safety Collaborative held during ASHP Summer Meeting, May 31-June 4, 2014, Las Vegas (
  • Quarterly Action Agenda (October - December 2013)

Special Announcements...

  • Unique 2-day program
    • Attend ISMP's Medication Safety INTENSIVE workshop in Washington, DC, on April 10-11, 2014. This workshop provides hands-on experiences with risk assessment, event investigation, error analysis, selecting error-reduction strategies, action planning, measuring effectiveness, Just Culture, and much more!
    • For details, visit:
  • ISMP webinar
    • Join us for our February 26 webinar, Reducing Hospital Readmissions: Successful Staff Intervention Strategies at Discharge. Learn firsthand how two organizations have used creative solutions to effectively decrease hospital readmissions. Our speakers will describe how they utilize medication reconciliation at discharge, implemented structured patient discharge education, and removed barriers to obtaining medications after discharge, resulting in a significant reduction in readmissions and improvement in patient care and satisfaction.
    • For details, visit:
  • 1-year Fellowships
    • ISMP offers several yearlong Fellowship programs that begin in July 2014 at the ISMP office near Philadelphia, PA. Learn more about the programs and how to apply at: Applications are being accepted until March 31, 2014.

Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas
  - Free Nursing CEs
Special Alerts
Group Purchasing Subscription
Newsletter Editions
Acute Care
Community/Ambulatory Care
Nurse AdviseERR
Long-Term Care AdviseERR
Safe Medicine
Home | Contact UsEmployment  |   Legal Notices | Privacy Policy | Help Support ISMP
 Med-ERRS | Medication Safety Officer Society Medication Safety Officers Society | Consumer Medication Safety For consumers
ISMP Canada | ISMP Spain  | ISMP Brasil  | International Group  | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved