February 2017

In this month’s issue:

  • What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials.
  • Potential issues with new basal insulin/GLP-1 fixed combinations. New safety challenges?


  • Pradaxa must be dispensed in its original container.
  • Lantus overdose tied to confusing vial label.
  • What's in a name - wrong resident errors.
  • When less than is greater than.
  • Errors involving less used therapies.

WORTH reading...

  • ED visits for elderly patients from adverse drug events. 

 Special announcements:

  • ISMP Survey on Verbal Orders
    • We’d like to know which drug classes you most commonly receive verbal orders for, and how often you have the opportunity to read back verbal orders. Please participate in our short survey by visiting:, and submit your responses by March 3, 2017

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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