December 2013

In this month’s issue:

Happy Holidays...We wish you joy, health, and happiness this holiday season! 

  • A long journey towards a safety-minded Just Culture. Part 1 – Where we’ve been. Having a punitive culture or a blame-free culture can lead to hiding or disregard of medication errors. True patient safety can only be achieved by moving to a Just Culture. This article is a first of a two part series on getting to a Just Culture.
  • SafetyWires: Discusses how the use of the abbreviation “U” was misread for a “4” leading to a medication error in a long-term care facility. A second Safety Wire discusses how topical analgesics can lead to chemical burns in residents.
  • All is not as it seems… Shows two examples of handwritten orders that can lead to medication dosing errors, and what can be done to prevent the misinterpretation of similar orders 
  • Health Alert… Discusses recent FDA reports on contaminated topical antiseptics and how to reduce risk of contamination and infection with improper topical antiseptic use.

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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