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ISMP
June 2014

In this month’s issue:

  • Misidentification of alphanumeric symbols.  Errors may occur during written or electronic communication because of similarities in appearance of alphanumeric symbols we use. This articles gives examples of medication errors resulting from such confusion and provides ways to help cope with the inadequacies of alphanumeric symbols that are prone to confusion and medication errors.
  • New Connectors Coming for Enteral Feeding Tubes. Discusses the transition plan for the new global design for enteral feeding tubes and adaptors that will be used by manufacturers for all enteral feeding tubes and syringes starting later this year.
  • All is not as it seems. Shows a recent medication error in a long term care facility involving confusion between Cardura and Coumadin.
  • SafetyWires: Discusses two recent events involving the use of insulin pens in multiple patients, resulting in notification of the 3,100 patients involved. Also discusses a method  for double-checking when there is no other person available
  • Report medication errors to ISMP. Share your medication safety stories and error reports in confidence by calling ISMP 1-800-FAILSAF(E), via our website (www.ismp.org/MERP), or by email (ismpinfo@ismp.org). Reporter identity and location remain strictly confidential and are never published. Anonymous reports are also accepted.

 

Report medication errors to ISMP. Share your medication safety stories and error reports in confidence by calling ISMP 1-800-FAILSAF(E), via our website (www.ismp.org/merp), or by email (ismpinfo@ismp.org). Reporter identity and location remain strictly confidential and are never published. Anonymous reports are also accepted. 

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