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May 4, 2006

  • Two manufacturer bar codes on one unit-dose package?

    Even when in compliance with the FDA bar-code ruling, manufacturer’s bar codes may cause confusion.
  • U see IU, I see IV

    Confusion due to the use of “IU” instead of “units.”
  • Drug safety “tools” on web

    Did you know that ISMP has made available a collection of useful drug safety tools in a single location. Newly included, with many other tools and convenient links, is a list of “DO NOT CRUSH” medications prepared by John F. Mitchell, PharmD, FASHP, of the University of Michigan, and a link to alphabetical and drug class listings of “Drugs With Black Box Warnings,” prepared by Joyce Generali, MS, RPh, FASHP, of Kansas University Medical Center.
  • Textbook errata

    Corrections are needed in AHFS Drug Information 2006 for VYTORIN (ezetimibe and simvastatin).
  • Guessing not appropriate

    Confusing labeling on KETEK (telithromycin) unit-dose packages leads to guessing about total dose.
  • Your reports at work

    American Pharamaceutical Partners (APP) has agreed to revise the labeling on adenosine injection, 12 mg/4 mL.
  • ISMP errata

    In the Quarterly Action Agenda of the April 20, 2006 issue of the ISMP Medication Safety Alert! (page QAA 2) incorrectly described a “code bug” with the ABACUS TPN Software. The error concerns vitamin K, NOT potassium. The original article in our March 9, 2006 issue contains correct information. Click here for a corrected replacement page.


Special Announcements…

  • ISMP-JCR Conference on Medication Reconciliation

    You’ll have three opportunities to join ISMP and Joint Commission Resources for a 1-day conference, Medication Reconciliation: An Organizational Approach to Improving Patient Safety Outcomes, to be held on the following dates at various locations:
    • June 13, 2006: Oakbrook Terrace, IL
    • September 26, 2006: Alexandria, VA
    • October 27, 2006: Dallas, TX

This program introduces you to an array of real-world strategies needed to implement a successful medication reconciliation program or to get an existing one on track. The conference features a presentation by Dr. Richard Croteau, one of the key Joint Commission physicians working with the Sentinel Event Advisory Group which recommends specific safety goals to the Joint Commission Board. The program offers a host of expert speakers, Q&A panels, peer discussion groups, and invaluable take-away materials. For details, please visit:


May 18, 2006

  • Tablet splitting: Do it only if you "half" to, and then do it safely .
  • JC changes standard

    After-hours access to medications by non-pharmacy personnel will no longer be allowed by JC after July 1, 2006

  • Read-back works

    Dramatic reduction in error rates shown by researchers using read-back during physician rounding

  • Proactively eliminating the risk of "never" events

    Prevalence should not be the only determinant of whether proactive steps should be taken for safety.

  • Message in our mailbox: Vincristine in minibags

Special Announcements…

  • Self-assessment data

    Thanks to all who participated in the 2005 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals. Preliminary aggregate data are now available to those who anonymously submitted their findings to ISMP. Visit and use the password provided during the data submission process to view the aggregate results.
  • ISMP teleconference

Our next teleconference, The Impact of Clinical Decision Support Systems: Alerts and Standardized Order Sets, will be held on June 29, 2006, from 1:30 to 3:00 p.m. EDT. The quantity and quality of safety alters generated by computerized prescriber order entry (CPOE) systems is often problematic. Our guest speaker, Eric Pifer, MD, Chief Medical Informatics Officer at the University of Pennsylvania, will discuss how best to use safety alerts and order sets to augment decision when prescribing drugs. Peter Kilbridge, MD, Associate Chief Information Officer for Patient Safety and Clinical Effectiveness at Duke University will moderate and discuss the Leapfrong initiative for evaluating hospital CPOE systems. For information, visit:

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