The following are excerpts from the newsletter

May 8, 2014

In this week's issue:

  • QuarterWatch (Drug hypersensitivity reactions) Allergic reactions second most frequently reported serious event
  • Help ISMP update its latest high-alert drug list
    • It has been more than 2 years since we last surveyed readers and updated ISMP’s List of High-Alert Medications. Please take a few minutes to complete our short survey by June 20, 2014, at:
  • Decimal commas a problem.
    • We were recently alerted about a product (GRANIX prefilled syringe) that uses a comma to separate the integers on the barrel of the syringe. Additionally, we revisit a previous error report when a comma was used instead of a period. 
  • Ten-fold error with trailing zero.
    • A pharmacist recently misread the maximum dose for IV niCARdipine (CARDENE) on the GlobalRPh website as 150 mg per hour when it actually listed the dose as “15.0 mg/hr.” GlobalRPh stated they were following the text listed in the official label, but has since removed the trailing zeros. We have also asked FDA to work with the sponsor to make the same changes in the approved label.
  • ACTIQ is not for sore throats!
    • A hospital reported three events in which a provider attempted to order ACTIQ (fentaNYL citrate oral transmucosal lozenge) to treat a sore throat. Strategies for safe use of Actiq are described in this SafetyBrief. 

Special announcements...

  • ISMP webinar
    • Join ISMP for our May 28 webinar, Managing Outcomes and Enhancing Safety: The Role of Protocol-Driven Care in Today's Healthcare Environment. Pharmacists have expanded their scope of practice to work collaboratively with physicians to provide protocol-driven care in an effort to improve patient outcomes. Join our guest speakers as they discuss protocol-driven care for treatment modalities such as pain management, nutritional support, and various drug therapies.
    • For details, visit:
  • Unique 2-day program
    • Attend ISMP's Medication Safety INTENSIVE workshop in Las Vegas on May 30-31. This workshop provides hands-on experiences with event investigation, risk analysis, error-reduction strategies, action planning, Just Culture, and more!
    • For details, visit:   

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