August 2014

In this month’s issue:

  • Splitting tablets challenges you and your residents.  Tablet splitting has become more commonplace for a variety of reasons.  However, this practice when done by those who administer medications in the LTC facility, rather than the pharmacy, can lead to medication errors.  This article discusses some of those errors and ways to prevent them.
  • Measuring How Full Your Bottle is. Discusses problems determining the amount of remaining drug solution for documentation of controlled substances with LORAZEPAM INTENSOL (LORazepam) 2 mg/mL, 20 mL and Morphine Sulfate Oral Solution 20 mg/mL 30mL bottles.
  • SafetyWire: Discusses errors involved the sound-alike, look-alike drugs (SALAD) OXcarbazepine and oxapozin, as well as MiraLAX and Miraplex.  Strategies for preventing errors involving SALADs are discussed.
  • Nursing CE Credit is Now Available. January through June 2014 issues of the ISMP Long-Term Care Advise-ERR newsletter. Information on how to obtain the CE is provided.
  • Interested in getting a review of your organization for medication safety? Discusses how ISMP can provide an on-site medication safety assessment and improve medication use in your facility.
  • Report medication errors to ISMP.
  • CMOE Survey. ISMP is conducting a short survey to understand the current level of implementation of computerized medication order entry and associated challenges in long-term care (LTC) facilities. Computerized medication order entry systems include computers into which a prescriber, nurse, or other healthcare provider enters all medication orders for residents, which are then electronically sent to the pharmacy that provides the medications to the LTC facility.  We are asking readers to complete the survey, whether or not you have implemented a computerized medication order entry system by September 19, 2014, by visiting:  Aggregate results will be shared in an upcoming issue of this newsletter.

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 (, or by email ( Reporter identity and location remain strictly confidential and are never published. Anonymous reports are also accepted. 

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