The following are excerpts from the newsletter

March 27, 2014

In this week's issue:

  • Still outside the bull's eye: 2014-2015 Targeted Medication Safety Best Practices (Baseline survey results)
  • Report improper screen display of therapeutic alternatives
    • We have previously described potentially improper formulary alternatives being displayed on ambulatory electronic medication ordering screens. If this problem is uncovered in your organization, we highly encourage you to contact your IT vendor immediately and to notify ISMP of any issues you may be having with this feature or other issues that result in presentation of possible wrong information.
  • Future devices for U-500
    • We are able to announce exciting information about two U-500 insulin projects that are underway at Eli Lilly and Company. Additionally, a medication safety fellow at Purdue University is conducting a survey to assess the prevalence of insulin pen utilization in the inpatient setting ( 
  • 4,200 need testing after pen misuse.
    • We describe a situation where, yet again, thousands of patients may have received an insulin injection from an insulin pen that was previously used for another patient. 
  • Diastat AcuDial requires setting and locking of the dose.
    • We have previously described issues with the DIASTAT ACUDIAL (diazepam rectal gel) delivery system. A recent event involving this device indicates that these issues have not been resolved.
  • IV saline substitutes.
    • Hospitals and health systems are encouraged to consider the compatibility of alternative IV fluids that are in use during the current shortage of 0.9% sodium chloride injection.
  • Safety is personal.
    • A new report, Partnering with Patients and Families to Provide the Safest Care,  from the Lucian Leape Institute at the National Patient Safety Foundation is available to readers along with access to a free webinar that will discuss the report and its recommendations. 
  • Oral vaccines.
    • In a previous newsletter, we mentioned that the only oral vaccine available in the US is the rotavirus vaccine. While that may be true among commonly administered vaccines, information about another oral vaccine (VIVOTIF, used for the prevention of typhoid fever) is provided. 
  • Trace elements shortage survey.
    • The American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) is interested in assessing how clinicians are managing current drug shortages with parenteral nutrition trace element products. Please take the short survey at:
  • Confusing concentration.
    • We recently received a report about a generic pseudoephedrine product with labeling that may be misleading.

Special announcements...

  • ISMP webinars
    • Join us on March 27 for our webinar, Addressing Safety Challenges with U-500 Insulin (And did you know U-200 and U-300 insulin products are now on the way?). Since only U-100 syringes are available for insulin administration, confusion exists when measuring doses of U-500 insulin. Given the increase in use of U-500 insulin, ISMP has received a growing number of reports related to serious 5-fold dosing errors with the drug. Learn more about common errors with U-500 insulin and how to prevent them. Also, share in the discussion of two new insulin concentrations in clinical trials, and assess their benefits and risks compared to U-100 and U-500 insulin.
    • Join ISMP for our April 23 webinar, Basal Bolus Insulin Therapy: Implementing Best Practices for Inpatients with Hyperglycemia. According to 2014 American Diabetes Association guidelines, non-critically ill, hospitalized diabetic patients should be managed with scheduled subcutaneous insulin doses that include basal, nutritional, and correctional components to maintain glucose control. Learn how to successfully transition an organization from a sliding scale insulin approach to this best practice. Learn the challenges faced during transition, the use of metrics to show improved outcomes, and the components of a competency-based educational program.
    • For details on both webinars, please visit:
  • 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 more!
    • For details, visit:

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