Putting Our

to kick off the 19th Annual ISMP CHEERS Awards

December 15, 2016 Volume 21 Issue 25

Dr. Reddy’s ASHP exhibit giveawaymeasures liquids incorrectly. Phar-macists attending the American Societyof Health-System Pharmacists (ASHP)Midyear Clinical Meeting last week in LasVegas may have visited the Dr. Reddy’sLaboratories booth in the exhibit hall. Ifso, then perhaps they picked up a “give-away” that looks like a shot glass. Ac-cording to Dr. Reddy’s Laboratories, thiswas meant as a novelty item. However, itappears to be designed for measuring liq-uids, possibly including liquid medications,rather than for measuring a shot of liquor.

Hopefully, pharmacists who receivedthese shot glasses noticed that the liquidmeasures imprinted on the glass seemto be way off the mark (Figure 1). Shotglasses  in the US typically hold 1.25 to

1.5 fluid ouncesof liquor.  Wecan’t attest tothe accuracy ofthe markingson the novelty“ g i v e a w a y ”shot glass, butthe 4 tablespoonmark on thesewould exceedthat amount,measuring 60

mL or 2 ounces! The teaspoonful markingsare also way off, with 3 “TSP” (approxi-mately 15 mL) measuring more than 2“TBSP” (approximately 30 mL).

Also, the use of non-metric liquid meas-ures is bad enough, but abbreviating ta-blespoon as “TBSP” and teaspoon as“TSP” has led to mix-ups between thesetwo measures (www.ismp.org/NAN/files/NAN-20150630.pdf).

continued on page 2—SAFETY briefs >continued on page 5—Challenges >

continued on page 2—CHEERS >

Potential issues with new basal insulin/GLP-1 fixed combinations New safety challenges?

Two new fixed-ratio combination insulin/glucagon-like peptide-1 (GLP-1) receptoragonists were approved last month by the US Food and Drug Administration(FDA). They each combine a basal insulin with a GLP-1 agonist and are administered

once daily. SOLIQUA 100/33, a Sanofi product (www.ismp.org/sc?id=2842), provides100 units of insulin glargine per mL and 33 mcg of lixisenatide per mL in a 3 mL single-patient-use pen. Novo Nordisk’s XULTOPHY100/3.6 (www.ismp.org/sc?id=2841) pro-vides 100 units of insulin degludec per mL and 3.6 mg of liraglutide per mL, also in a3 mL single-patient-use pen. Soliqua 100/33 and Xultophy 100/3.6 differ from otherinsulin-containing products and present new potential safety issues.

Figure 1. Danger: Liquidmeasurement markings aregrossly incorrect on this Dr.Reddy’s “giveaway” shotglass, which might be usedto measure medicine doses.

This month, ISMP rounded up an impressive group of individuals and organizations tohonor and recognize with its 2016 CHEERS Awards, which were presented at a gala dinner heldon December 6 at Stoney’s Rockin’ Country in Las Vegas. Please join us in congratulatingthe following medication safety trailblazers who have created best practices, programs, and re-sources that are helping to prevent medication errors and improve the quality of patient care.

CHEERS rang out for a large health system’s impressive leadership commitmentto comprehensive implementation of the 2014-2015 ISMP Targeted Med-ication Safety Best Practices for Hospitals.

Ascension is the largest nonprofit health system in the US and includes 141 hospitals.Executive leadership made it a top priority to integrate all the ISMP best practices into theirhospitals’ culture and operations, with the goal of improving patient safety and outcomes. As-cension identified potential barriers to implementation, established multidisciplinary teams,held monthly coaching calls, and shared tools and resources. They also conducted pre- andpost-surveys and engaged an independent consulting team to evaluate compliance. This initiativeresulted in an increase in best practice adoption at each site that was well above the nationalaverage. Ascension leadership has committed to engage in the same process to implement the2016-2017 ISMP Targeted Medication Safety Best Practices for Hospitals.

A national professional organization’s safety committee received CHEERSfor its cumulative and interdisciplinary efforts to advance safety in everyfacet of parenteral nutrition support.

The American Society for Parenteral and Enteral Nutrition’s (ASPEN) ParenteralNutrition Safety Committee significantly increased awareness and educational resources

December 15, 2016 Volume 21 Issue 25 Page 2

to prevent errors related to parenteral nutrition. The committee began in 2011 as a multidis-ciplinary task force established as a result of an ASPEN safety summit that was attended by46 key stakeholders. It has since published numerous recommendations, including severaladdressing processes related to the electronic health record, parenteral prescribing order re-view, compounding, and labeling. The committee has conducted a safety survey and gapanalysis, collected data on medication errors with parenteral nutrition, and developed toolsand specific competencies for staff involved in parenteral nutrition prescribing, dispensing,and administration. In addition, the committee developed a certificate program to educatemembers of the healthcare team who work with parenteral nutrition about safe practices.More than 1,300 clinicians have participated in the program, and ASPEN is working towardsgaining funding to share the certificate program with pharmacy residents as well.

CHEERS were presented to a health system clinical group that transformed apharmacy intervention program to ensure real-time clinical alerts and timelyadjustments in patient care.

The HCA Clinical Services Group created a Clinical Pharmacist Workflow model thatuses evidence-based decision support and real-time information to alert pharmacists to op-portunities for reducing the risk of patient harm from medication-related issues. This initiativeidentified ways to embed safety throughout the entire medication management system,from procurement to monitoring. The real-time care provided by the model led to improvedproductivity and streamlined workflow. Between 2014 and 2015, the model was deployed in153 HCA–affiliated hospitals, with a 48% decrease in adverse drug events since implemen-tation. In addition, hundreds of interventions have led to reduced risk for patients. Forexample, pharmacists have partnered with nursing to intercept incorrect patient weightsusing multiple triggers that may suggest an incorrect entry. The Clinical Pharmacist Workflowmodel also has allowed pharmacists to participate in more patient care related activities,such as multidisciplinary team rounds and providing medication history and reconciliationservices.

CHEERS rang out for a nonprofit coalition that has played a vital role in im-munization education and advocacy aimed at both healthcare professionalsand consumers.

The Immunization Action Coalition (IAC), created and sustained by its unique partnershipwith the US Centers for Disease Control and Prevention (CDC), helps facilitate communicationabout the safety, efficacy, and use of vaccines within the broad immunization community ofpatients, parents, healthcare organizations, and government health agencies. It works toreduce the incidence of 23 vaccine-preventable diseases by raising immunization rates andpreventing vaccine errors, including omissions. The Coalition has developed free resources,including hundreds of highly reviewed and updated educational materials for healthcareproviders and patients, and maintains a website for healthcare professionals(www.immunize.org) and a website for the general public (www.vaccineinformation.org).Providers and patients can find the answers to dozens of frequently asked questions aboutall vaccines available in the US on these sites. Its online publications include the weeklyemail information service, IAC Express, the quarterly periodicals Needle Tips and VaccinateAdults!, and the popular feature “Ask the Experts.”

An outstanding individual received loud CHEERS for his tireless work to im-prove medication safety in the operating room and during the delivery ofanesthesia.

> CHEERS—continued from page 1

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If you picked up these shot glasses, itwould be safest to discard them imme-diately. No one wants to chance some-one at work or in your household meas-uring medications with these inaccurateglasses. We informed Dr. Reddy’s Labo-ratories about this situation and hope thecompany will take our suggestion to fol-low through as soon as possible with aletter to ASHP Midyear attendees, askingthat these be discarded. If you want tocontact the company directly about thisissue or other product complaints or drugsafety inquiries, please call the com-pany’s toll free number (9 a.m. to 7 p.m.)at 888-375-3784, or contact the companyvia email at: medinfo@drreddys.com. TheUS Food and Drug Administration (FDA)is also aware of the issue.

FentaNYL diversion alert. A pharma-cist contacted us to let us know about adiversion and tampering incident thathad occurred at his hospital, which wasfelt to be related to the labeling style ofthe West-Ward Pharmaceuticals fen-taNYL 50 mcg/mL, 2 mL vial. The paperlabeling extends to the top of the flip-top cap (Figure 1). This had been care-

fully pulledback, and theflip-top caphad been re-moved. Then,the fentaNYLmedicationhad beenw i t h d r a w nfrom the vialand replacedwith sterilewater for in-jection. Theflip-top capwas then re-placed andheld in placeby the label,

which had enough adhesive to keep itin place, disguising the tampering anddiversion. In fact, the label has enoughglue to cause the vials to stick together

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cont’d from page 1

Figure 1. The fentaNYL labelthat extends above the flip-topcap was carefully peeledaway, the medication wasremoved and replaced withsterile water, the cap wasreplaced, and then the labelwas pulled up around the capto hide any signs of tampering.

The next newsletter will be published in 2017 on January 12. See you next year!

December 15, 2016 Volume 21 Issue 25 Page 3

continued on page 4—SAFETY briefs >

in the 25-vial carton, sometimes resultingin torn or crinkled labels on vials thathave not been tampered with. 

We contacted West-Ward but have notyet heard whether any changes areplanned.

HydrOXYzine–hydroxyurea mix-up.A pharmacist intended to enter an orderfor liquid hydrOXYzine 25 mg every6 hours on a scheduled basis for itching(not prn), but accidentally chose liquidhydroxyurea from an order system drop-down list. Liquid hydroxyurea is an in-stitutionally compounded product of100 mg/mL, while hydrOXYzine is com-mercially available as 10 mg/5 mL. Thehospital required that the purpose beincluded for “as needed” orders (prn)but not scheduled doses, so that infor-mation was not added to the instruc-tions. Also, there was no dose rangechecking for hydroxyurea, so a 25 mgdose didn’t signal an alert. The orderwas verified by another pharmacist andthen dispensed and administered for48 hours until medical staff questionedwhy the patient was receiving hydrox-yurea. There was no apparent harm tothe patient, but it certainly was a con-cern to the hospital because the errorcould have had serious consequences.Such an error could result in deprivinga patient with itching from receivinghelpful therapy, as happened here, or ifit resulted in a missed dose of hydrox-yurea, a patient with sickle cell diseaseor one who needed the cytotoxic agentfor oncologic use would have missed acritically needed dose.

The reporting hospital is considering theuse of tall man letters for hydroxyurea.We’ve recommended tall man letters forhydrOXYzine for some time but have notmade any recommendations for hydroxy-urea. One problem with using tall manletters for hydroxyurea is that the first 7letters of each name are identical. It’snot until the 8th letter that tall man lettercharacters would appear (e.g., hydroxy-

Dr. Robert Stoelting has devoted his career to spearheading efforts to improve the safetyof patients undergoing anesthesia and in the operating room. During his nearly 20 years asPresident of the Anesthesia Patient Safety Foundation, he has helped advocate for crucialmedication safety initiatives, provide vital educational programs and workshops, and offerfree resources for error reduction, including a newsletter with worldwide circulation of morethan 122,000 copies per issue. Dr. Stoelting’s dedication to collaboration has led to numerousnational consensus conferences that have brought together a wide range of stakeholders toaddress topics such as patient-controlled analgesia, use of high-alert medications, labelingof medications in the operating room, and use of pharmacy-prepared syringes by anesthesiaproviders. The combined impact of Dr. Stoelting and the Foundation’s initiatives, along withothers in the field, has been a 10- to 20-fold reduction in mortality and catastrophic morbidityfor healthy patients undergoing routine anesthesia.

One individual with significant career-long contributions to patient safetywas honored with a special CHEERS—the 2016 ISMP Lifetime Achieve-ment Award.

David Marx, JD, is a true pioneer in the safety world, from developing human factors riskmodeling methods to being the father of the “Just Culture” accountability model. He hasmore than two decades of experience in transforming workplaces in high-risk industries toachieve highly reliable outcomes and has brought lessons learned from aviation, aerospace,and transportation into the healthcare arena. Marx, who is currently CEO of OutcomeEngenuity, has authored a patient safety guide for the National Institutes of Health andadvises the US Agency for Healthcare Research and Quality (AHRQ) on safety issues. Healso has authored two books on workplace accountability, Whack-a-Mole: The Price We Payfor Expecting Perfection, and Dave’s Subs: A Novel Story about Workplace Accountability.

During his acceptance speech, Marx described the pillars that are required to support patientsafety in healthcare:

Systems Engineering: The interdisciplinary science of designing and managing the complexprocesses, equipment, interfaces, and the environment in healthcare, in a manner that max-imizes patient safety and reliability.

Root Cause Analysis (RCA) and Causal Diagramming: Identifying the root causes thatled to an actual or potential adverse outcome, and then creating a visualization of the rela-tionship between the given outcome, all the behavioral and system factors that influencedthe outcome, and the causes behind each behavioral or system factor.

Human Factors and Behavioral Economics: Understanding the psychological, social,cognitive, and emotional factors that drive human behavioral choices and cause human error,and using that information in the design of systems and processes to complement humancapabilities, the implementation of change strategies, and the just management of staff be-havioral choices.

Just Culture and the Law: A safety-supportive model of shared accountability wherehealthcare institutions are accountable for the systems they design; for supporting the safebehavioral choices of patients, visitors, and staff; and for responding to staff behaviors in afair and just manner. In turn, staff are accountable for the quality of their behavioral choices(human error is not a behavioral choice) and for reporting hazards, errors, and system vulner-abilities. Legal reform may be necessary to better support patient safety, as our current legalsystem often punishes human error and supports a severity bias towards the outcome.

> CHEERS—continued from page 2

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© 2016 ISMP. Reproduction of the newsletter or its content for use outside your facility, including republication of articles/excerpts or posting on a public-access website, is prohibited without written permission from ISMP.

December 15, 2016 Volume 21 Issue 25 Page 4

> CHEERS—continued from page 3UREA). Sometimes, depending on howbrand and generic names are displayed,the final letters of the drug name maybe overlooked during drug selection,which apparently happened here. Al-though hydroxyurea liquid is a pharmacycompounded product, it may makesense to primarily identify the drug asHYDREA or DROXIA, brand names forcurrently available commercial hydrox-yurea capsule products. Also, somehospitals strive to include a purpose formedications whether scheduled or prn.That may have helped prevent this errorfrom happening (e.g., why would hy-droxyurea be used for itching?).

More outpatient oral cancer drugsshould be in blister packs. Certainoral cancer drugs would benefit greatlyfrom safer packaging, such as child-re-sistant blister packs. We’ve asked theUS Food and Drug Administration (FDA)to give this more consideration.

Our medication safety colleagues at Pre-scrire, a French publication, recentlywrote about a 30-month-old child whoswallowed 8 tablets of mercaptopurine50 mg (400 mg). The drug was actuallyprescribed for his 7-year-old sister withacute lymphoblastic leukemia. Althoughthe child initially suffered liver cell dam-age, this resolved within 12 days, andthere were no permanent sequelae. Itwas learned that the tablets were dis-pensed in a prescription bottle with achild-proof cap. It is unknown how thedrug was actually accessed by the child.However, improperly replaced caps area well-known problem with bottles.

Incidents like this one are a reminderthat child-resistant blister packaging thatmeets the requirements of the PoisonPrevention Packaging Act can help re-duce the risk of poisoning, as can keep-ing all medications out of the reach andsight of children. Dispensing certaindrugs in blister packs that also serve ascalendar packs can improve adherencein addition to preventing errors.

Socio-technical Probabilistic Risk Assessment (ST-PRA) and Model-based RiskManagement: Prospective vulnerability analyses that link process failures with scientificallyderived estimates of process failure rates, human error rates, and behavioral norms, yieldinga more accurate picture of why and how often these failures affect patient outcomes. Theseanalyses track all possible pathways that can lead to an adverse outcome and allow all com-binations of tasks, behavioral choices, and system failures to be considered in combinationwith one another when formulating a risk-mitigation plan.

One of the highlights of the evening was a noteworthy presentation fromthe CHEERS Keynote Speaker about protecting young children from acci-dental overdoses.

Sincere thanks are extended to the evening’s keynote speaker, Daniel Budnitz, MD, MPH,Capt., USPHS. Dr. Budnitz directs the Medication Safety Program at the CDC and hasauthored more than 50 publications on medication safety, public health surveillance, andinjury prevention. He presented a public health approach to reduce medication overdoses inchildren less than 5 years old, touching upon real-world successes such as the PROTECT Ini-tiative, an innovative collaboration bringing together public health agencies, private sectorcompanies, professional organizations, consumer advocates, and academic experts to developstrategies to keep children safe from unintentional overdoses.

Since the 1970s Poison Prevention Packaging Act, which required child-resistant caps formost medications, mortality from overdoses has declined dramatically in children less than5 years of age. However, emergency department (ED) visits and hospitalizations due to over-doses in this age group increased between 2000-2011. To help address this, the industry hasbegun packaging some medications in unit doses, with each oral solid dose in individualchild-resistant packaging to prevent access to large quantities of unauthorized medicationsif the packaging is breached. The use of flow restrictors in bottles of oral liquid medicationswas also instrumental in reducing morbidity and mortality from unauthorized access to med-ications. Due to these packaging advances, along with metric-only dosing and dosing devices,and parent education about safe drug storage, ED visits due to unauthorized access to med-ications in children less than 5 years has decreased since 2011.

We also would like to thank the organizations and individuals who attended and/or supportedthis year’s CHEERS Awards and helped us celebrate these extraordinary leaders. Visitwww.ismp.org/Cheers for a list of contributors and winners, and visit www.ismp.org/support forways you can help ISMP continue to fight against preventable medication errors.

We look forward to another great year of working together to improve medication safety in 2017!

cont’d from page 3

Apply now for an ISMP FellowshipISMP is now accepting applications until March 31 for two unique Fellowship programs:

The ISMP Safe Medication Management Fellowship, sponsored by Baxter Inter-national Inc., is a yearlong learning opportunity at the Horsham, PA, office of ISMP.

The FDA/ISMP Safe Medication Management Fellowship is a yearlong learningopportunity at the Horsham, PA, office of ISMP (6 months) and the office of the USFood and Drug Administration’s (FDA) Division of Medication Error Prevention andAnalysis in Silver Spring, MD (6 months).

For details, see page 7 of the newsletter or visit: www.ismp.org/profdevelopment/.

December 15, 2016 Volume 21 Issue 25 Page 5

ISMP MedicationSafety Alert! AcuteCare (ISSN 1550-6312)© 2016 Institute for SafeMedication Practices

(ISMP). Subscribers are granted permission to redistributethe newsletter or reproduce its contents within their prac-tice site or facility only. Other reproduction, including postingon a public-access website, is prohibited without writtenpermission from ISMP. This is a peer reviewed publication.

Report medication and vaccine errors to ISMP:Please call 1-800-FAIL-SAF(E), or visit our website at:www.ismp.org/MERPor www.ismp.org/VERP. ISMP guar-antees the confidentiality of information received and re-spects the reporters’ wishes regarding the level of detailincluded in publications.

To subscribe: www.ismp.org/sc?id=382

Editors: Judy Smetzer, BSN, RN, FISMP; MichaelCohen, RPh, MS, ScD (hon), DPS (hon); Ann Shas-tay, MSN, RN, AOCN; Russell Jenkins, MD; RonaldS. Litman, DO. ISMP, 200 Lakeside Drive, Suite 200,Horsham, PA 19044. Email: ismpinfo@ismp.org; Tel:215-947-7797; Fax: 215-914-1492.

ismp.org consumermedsafety.org twitter.com/ISMP1 facebook.com/ismp1 medsafetyofficer.org

ISMP webinar Please join us on January 25, 2017, for ourfirst webinar of the new year, Starting atthe Top: Strategies to Enhance the Safetyof Prescribing Practices. Participants willlearn about frequent harmful errors involv-ing breakdowns in the prescribing processas reported to a state reporting program,along with first-hand observations of theorganizational factors that contribute toprescribing errors and the challenges hos-pitals face making improvements. Ourspeakers will also outline key safety strate-gies for establishing a standardized ap-proach for prescribing medications. For de-tails, visit: www.ismp.org/sc?id=349.

Plan to attend a 2017 MSI workshopIf you were unable to join your colleaguesat the ISMP Medication Safety Intensive(MSI) workshop at the December 2016ASHP Midyear Clinical Meeting becauseit was sold out, sign up early for a programin 2017! Upcoming dates and locations forthis unique hands-on program are: March23-24, 2017, in Austin, TX; September 21-22, 2017, in Hackensack, NJ; and December1-2, 2017, in Orlando, FL. For more informa-tion or to register, go to: www.ismp.org/educational/MSI/default.asp.

> Challenges—continued from page 1

Mistaking the products as containing only insulinOne potential safety issue is that practitioners may mistakenly think that these productscontain only insulin. This is one reason why computer system drop-down lists and phar-macy communications about these products should use the ratio expressions (i.e., Xul-tophy 100/3.6 and Soliqua 100/33), which hopefully will help to indicate to users that theproduct contains two different ingredients. The ratio expression is designed to expressthe ratio of insulin to GLP-1 agonist per mL (e.g., Soliqua 100/33 contains 100 units ofinsulin glargine and 33 mcg of lixisenatide per mL). In contrast to the ratios used for in-sulin-insulin combination products such as NOVOLOG MIX 70/30 (insulin aspart prot-amine, insulin aspart) or HUMALOG MIX 50/50 (insulin lispro protamine, insulin lispro),the ratio expressions for Soliqua 100/33 and Xultophy 100/3.6 do not sum up to 100%,which should also help practitioners differentiate them from insulin-only products.

If your system uses generic names, make sure both ingredients are displayed and nottruncated. However, keep in mind, the first name practitioners will see is “insulin.” Thatmay contribute to practitioners mistaking these as insulin-only products. Using the brandnames, ideally with a hover over presentation of the complete generic names, couldreduce the risk of an error. Also, counsel patients when initiating Soliqua 100/33 and Xul-tophy 100/3.6 so they understand the products contain both insulin and a GLP-1 agonist.

Dosing is based on insulin units, not the GLP-1 agonist componentDosing of these products is expressed based on the number of insulin units (the pendials the dose in insulin units only). The package insert for each product has a table thatindicates the amount of GLP-1 agonist per insulin unit, but including the GLP-1 agonistdose is not recommended when prescribing these products. If an order is communicatedwithout the ratio expression (“Soliqua 40 units” or “Xultophy 35 units”), practitionerscould think it’s a new insulin product and not recognize there is a GLP-1 agonist containedwithin. This could lead someone to prescribe a separate GLP-1 agonist to go along withwhat is thought to be the patient’s only insulin dose. 

Fixed ratios of insulin to GLP-1 agonistBoth Soliqua 100/33 and Xultophy 100/3.6 may be used at doses containing less than thecurrently approved doses for the single ingredient GLP-1 component. For example, theSoliqua 100/33 starting dose is 15 units per day, which contains 5 mcg of lixisenatide.However, the recommended starting dose for single ingredient lixisenatide (ADLYXIN)is 10 mcg daily. Converting between these products and the individual ingredients canbe problematic since the dosing is not the same. For example, if a hospital stocks onlyXultophy 100/3.6, the pen will not provide the same dose achievable with the individualingredient components (e.g., insulin degludec pens and liraglutide pen).

Not recommended for concurrent use with other products containing GLP-1 agonists

These products are not recommended for use in combination with any other productcontaining a GLP-1 agonist because of the risk of overdose. The package insert recom-mends using alternative antidiabetic products if patients require a Soliqua 100/33 dailydosage below 15 units or over 60 units. For Xultophy 100/3.6, use alternative antidiabeticproducts if patients persistently require less than 16 units or more than 50 units.

ISMP thanks Ariane O. Conrad, PharmD, BCACP, CDE, FISMP, at the US Food and DrugAdministration (FDA) Division of Medication Error Prevention and Analysis, and StevenMeisel, PharmD, CPPS, at Fairview Health Services in Minneapolis, MN, for their assistancein preparing this article for publication.

December 15, 2016 Volume 21 Issue 25 Page 6

Ivyruth Andreica, BSN, PharmD, FISMP, Ivenix, Inc., Amesbury, MA•Michelle Bell, RN, BSN, FISMP, CPPS, Pennsylvania Patient Safety Authority, Harrisburg, PA•Kelly Besco, PharmD, FISMP, CPPS, OhioHealth, Columbus, OH•Kevin Brooks, RPh, MBA, FACHE, UC Health–West Chester Hospital, West Chester, OH•Thomas Burnakis, PharmD, Jacksonville, FL•Stacy Carson, PharmD, BCPS, FISMP, North Florida Regional Medical Center, Gainesville, FL•Robert Cisneros, RPh, PhD, Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC•Linda Cohen, RN, MPH, MSN, CDE, BC-ADM, Downstate Medical Center, Brooklyn, NY•Lebron Cooper, MD, University of Tennessee Health Science Center, Memphis, TN•Rabih Dabliz, PharmD, FISMP, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates•Bob Feroli, PharmD, FASHP, The Johns Hopkins Hospital, Baltimore, MD•Evgeny Gorodetsky, PharmD, SUNY Upstate Medical University, Syracuse, NY•John Gosbee, MD, MS, Red Forest Consulting & University of Michigan, Ann Arbor, MI•Peggi Guenter, PhD, RN, FAAN, American Society for Parenteral and Enteral Nutrition (ASPEN), •Silver Spring, MDBeverly Holcombe, PharmD, BCNSP, FASHP, FASPEN, American Society for Parenteral and •Enteral Nutrition (ASPEN), Silver Spring, MDPatrick Howell, PharmD, UC Health, Cincinnati, OH•Jamie Irizarry, BSN, MS, CCRN-K, The Children’s Hospital of Philadelphia, Philadelphia, PA•Jane Jeffrie Seley, DNP, MSN, MPH, GNP, BC-ADM, CDE, CDTC, FAAN, FAADE, NewYork-Presbyterian •Hospital/Weill Cornell Medicine, New York, NYDonald McKaig, RPh, CDOE, Lifespan, Providence, RI•Steve Meisel, PharmD, CPPS, Fairview Health Services, Minneapolis, MN•Rachel Meyers, PharmD, BCPS, BCPPS, Rutgers University, Saint Barnabas Medical Center, Livingston, NJ•Raymond Muller, RPh, MS, FASHP, Memorial Sloan-Kettering Cancer Center, New York, NY•Michael O’Connor, PharmD, MS, FISMP, Intermountain Healthcare Pharmacy Services, Murray, UT•Shawn Osborne, PharmD, MBA, University Hospitals, Cleveland, OH•María José Otero, PhD, PharmD, ISMP-Spain, Salamanca, Spain•Deborah Pasko, PharmD, MHA, American Society of Health-System Pharmacists, Bethesda, MD•Joanne Peterson-Falcone, RN, CCRN (alum), FISMP, Memorial Health System, Colorado Springs, CO•Alan Polnariev, PharmD, MS, New York, NY•Amanda Prusch, PharmD, BCPS, Lancaster General Health, Lancaster, PA•Jennifer Reddan, PharmD, FASHP, Indiana University Health, Indianapolis, IN•James Rinehart, RPh, MS, FASHP, Winovation Associates LLC, Indianapolis, IN•Dan Ross, PharmD, D Ross Consulting, Glendale, CA•Edward Schuman, MD, Holy Redeemer Hospital, Meadowbrook, PA•John Senders, PhD, ISMP Canada, Toronto, Canada•Ali-Reza Shah-Mohammadi, PharmD, MS, FISMP, CMQ, •The University of Texas MD Anderson Cancer Center, Houston, TXDaniel Sheridan, RPh, MS, Marion General Hospital, Marion, OH•Elizabeth Wade, PharmD, BCPS, Concord Hospital, Concord, NH•Christopher Walsh, PharmD, FISMP, Saint Joseph Medical Center, Reading, PA•Amanda Wollitz, PharmD, FISMP, Florida Hospital, Orlando, FL•Annie Yang, PharmD, BCPS, FISMP, NYU Langone Medical Center, New York, NY•

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

Special Recognition…Our 2016 Acute Care ISMP Medication Safety Alert!Advisory BoardProduction of this peer reviewed newsletter would not be possible without the assistance of a reliable andtalented clinical advisory board. As 2016 nears an end, we want to thank each of the following members of theadvisory board for their dedication to making this newsletter a valuable medication safety resource for clinicians.

Gregory BaldwinDavid Bates, MD, MScMichael Cohen, RPh, MS, ScDMark Cziraky, PharmD, CLS, FAHAJanice Dunsavage, RPh, MS

(Board Chair)Rebecca Finley, PharmD, MSRonda Hughes, PhD, MHS, RN, CLNC,

FAANRussell Jenkins, MDLou Martinelli, PhD, PharmDMargaret McGoldrick, MBAMarty Minniti, RNDonald Phillips, BS, PharmD, FCPPDavid U, BScPhm, MScPhmL. Albert Villarin, Jr., MD, FACEPZane Wolf, PhD, RN, FAAN

ISMP Board of Trustees

Ghadeer Banasser, PharmD, CPHQRenee Brehio, MAMichael Cohen, RPh, MS, ScD (hon) Rachel Cohen, MS, RDMelinda Cozza-RouthWilliam Cunningham, BSEE, MCSE,

CANStephanie DeGraw, PharmDSharon DickerMatthew Fricker, RPh, MS, FASHPMichael Gaunt, PharmDNancy Globus, PharmDJennifer Gold, MSN, RN, OCNNicole GraserMatthew Grissinger, RPh, FASCP, FISMPDonna Horn, RPh, DPhRussell Jenkins, MDCeleste Karpow, PharmD Arounsavanh KhemdyRebecca Lamis, PharmD, FISMPStaley Lawes, PharmD, BCPSMarci Lee, PharmD, FISMPRonald Litman, DOMichelle Mandrack, MSN, RNChristina Michalek, BS, RPh, FASHPThomas MooreKristine Needleman, RPhSusan O’DonnellJordann OgleSusan Paparella, MSN, RNSusan Proulx, PharmDHeather Quarry, CPADarryl Rich, PharmD, MBA, FASHPAnn Shastay, MSN, RN, AOCNLisa ShiroffJudy Smetzer, BSN, RN, FISMPMimi SpiegelMaximilian Straka, PharmDAllen Vaida, BSc, PharmD, FASHP

ISMP Staff

ISMP Safe Medication Management Fellowship

Location and Term: This 12-month Fellowship, sponsored by Baxter International Inc., commences summer 2017 at the Hor-sham, Pennsylvania (near Philadelphia) office of ISMP. Relocation to the Horsham/Philadelphia area is required.

Description: The Fellowship offers a nurse, pharmacist, or physician with at least 1 year of postgraduate clinical ex-perience an unparalleled opportunity to learn from and work with some of the nation’s experts in medication safety. This Fel-lowship is open to US citizens only. Now in its 25th year, the Fellowship allows the candidate to work collaboratively withpractitioners in various healthcare settings to assess and develop interdisciplinary medication error-prevention strategies.

FDA/ISMP Safe Medication Management Fellowship

Location and Term: This 12-month Fellowship commences August/September 2017. The Fellow will spend 6 months at the Hor-sham, Pennsylvania (near Philadelphia) office of ISMP and 6 months at the Silver Spring, Maryland (near Washington, DC) office of theUS Food and Drug Administration (FDA). Relocation to the Horsham/Philadelphia and Silver Spring/Washington, DC, area is required.

Description: The Fellowship, open to a healthcare professional with at least 1 year of postgraduate clinical experience,is a joint effort between ISMP and FDA’s Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, andDivision of Medication Error Prevention and Analysis. This Fellowship is open to US citizens only. The Fellowship allows the candi-date to benefit from ISMP’s years of experience devoted to medication error prevention. At FDA, valuable regulatory experience isgained by working with the division focused on medication error prevention.

How to ApplyInformation and applications can be found at: www.ismp.org/profdevelopment/.

Applications can also be requested by calling 215-947-7797.

The application deadline for all Fellowship Programs is March 31, 2017.

A competitive stipend, paid vacation, and health benefits are provided with all Fellowship programs.

Safe Medication Management Fellowships

ISMP is now accepting applications for two unique 2017-2018 Fellowship programs

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