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The following are excerpts from the newsletter

  • The virtues of independent double checks – they really are worth your time!
  • New color code for 25 gauge safety needles may lead to confusion and errors - Problems with a TB syringe (25 gauge needle affixed) that is color-coded with an orange plunger cap and label, the same color used on insulin syringes and vial caps.
  • Worth Repeating - People often seem hesitant when we suggest that they designate volume only in mL, not in cubic centimeters (cc). But there’s good reason for making this recommendation: the abbreviation “cc” has been misinterpreted repeatedly.
  • More on sterile water for injection - Failure to recognize the danger of infusing plain sterile water IV seems to be more widespread than we thought.
  • Bar-coding teleconferences - If your medication safety team has been talking about the use of a bar-coded drug administration system as one of your approaches to reduce medication errors, consider joining us for a series of live teleconferences presented on April 3, 8, 17, and 24. Along with several nationally recognized experts, we’ll provide independent, objective information about currently available bar-code systems, assessment of readiness, implementation strategies, tips and time savers, what works and what doesn’t, and much more. Visit our web site at to register and for additional information on topics and speakers for each program. It’s an important conference series you won’t want to miss.
  • Congratulations to the ISMP Medication Safety Contest winners! In January, we invited subscribers to join us in celebrating National Patient Safety Week in March by participating in a contest about involving patients and the community in medication safety initiatives. The following health systems submitted winning entries; Fletcher Allen Health Care in Burlington, VT., Gunderson Lutheran in La Crosse, WI., and Aurora Health Care from Milwaukee, WI.

  • Safety Briefs
    • Beware of mistaking aripiprazole (ABILIFY) for a proton pump inhibitor (PPI).
    • The labels on newer bottles of INFANTS’ TYLENOL CONCENTRATED DROPS (acetaminophen) do not include the concentration.
    • Lack of proper spacing between the order date (12-24-02) and the insulin dose (6 units) nearly led to an error
    • A “New & Improved” formulation of the brand KAOPECTATE is available with bismuth subsalicylate replacing attapulgite as its active ingredient.
    • Two extra doses of oral colchicine 0.6 mg were given to a patient when the abbreviation “PC” was used to signify that a daily dose should be given after one meal each day
    • Nursing Matters - ISMP is excited to announce that we will be publishing a newsletter written especially for front-line nurses. Called the ISMP Medication Safety Alert! Nursing Matters, this monthly, two-page newsletter will be offered free to nurses during 2003 through a unrestricted grant by Eli Lilly and Company used to fund the start-up of this important publication. While the drug safety issues covered in the ISMP Medication Safety Alert! Acute Care edition are certainly applicable to nurses, anecdotal evidence suggests that crucial medication safety information may not be reaching very busy front-line nurses who are continuously overwhelmed with information related to a wide variety of important issues. Through its unique design, it’s anticipated that nursing matters will be just the vehicle needed to deliver medication safety information to nurses who administer medications. To determine its success, we will be using focus groups and surveys to evaluate the interest, value, and impact of nursing matters, and the best way to distribute important medication safety information to nurses in the future. ISMP plans to distribute the monthly newsletter by e-mail to a single nursing representative in each hospital or health system, who will take responsibility to distribute the newsletter to all front-line nurses in the organization. Please have a representative from your hospital or health system visit our web site later this week to subscribe to this free publication.

March 20, 2003

  • Last week was National Patient Safety Week - and what a week it was!
  • Even more about sterile water! - Reports about errors and near misses involving IV infusion of sterile water for injection continue to arrive.
  • Safety Brief
    • Confusion between ZETIA (ezetimibe) and ZESTRIL (lisinopril).
    • Patients still need short-acting insulin along with LANTUS (insulin glargine, Aventis) to ensure proper glycemic control.
    • Watch out for Abbott's labetalol injection and ESI Lederle's DOPRAM (doxapram) vials, especially in the OR, for look-alike confusion.
    • Sound-alike alert! Recent reports indicate confusion between RECOMBIVAX HB (hepatitis b vaccine, recombinant) and COMVAX (haemophilus b conjugate vaccine with hepatitis b vaccine).
    • More precautions for the "New & Improved" KAOPECTATE. The bismuth subsalicylate can lead to darkened or black-colored stool.
  • ISMP bar code teleconference series - Last week's announcement by the federal government about new requirements for bar codes on all pharmaceutical packages will, no doubt, stimulate the implementation of this technology. So don't forget to register for the ISMP bar-code teleconference series starting April 3, 2003, and continuing on April 8, 17, and 24. The series will provide your medication safety team with objective information about currently available bar-code systems, assessment of readiness, implementation strategies, tips on what works and what doesn't, and much more. Visit our web site at to register and for information on topics and speakers for each program. It's an important conference series you won't want to miss.
  • Sign up for ISMP's newest newsletter: ISMP NurseAdvise-ERR - Over 1,000 locations have already registered to receive a complimentary subscription to our latest newsletter designed especially for front-line nurses. Starting April, this monthly newsletter will be sent by e-mail to a nursing representative at each site who then will redistribute it to all nurses in the organization. While we originally envisioned calling this newsletter Nursing Matters, we have changed its name to the ISMP Medication Safety Alert! Nurse Advise-ERR to better reflect its purpose - to provide nurses with practical advice on how to prevent medication errors. The newsletter will be offered free during 2003 through an unrestricted grant from Eli Lilly and Company. There is still time to register by visiting our web site at

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