ISMP believes the ultimate measure of success for error reporting programs is not the number of reports received but rather the amount of patient harm prevented as a result of the reports. Our most recent free featured newsletter article presents tips and best practices to increase the effectiveness of your reporting system: https://www.ismp.org/node/27103

Transform the way you think about medication safety by joining us at our last virtual Medication Safety Intensive workshop of the year on December 2-3, 2021! Take advantage of this unique opportunity maximize your error prevention efforts while gaining the knowledge, resources, and tools needed to be a successful medication safety leader.

This workshop sells out quickly, so save your seat soon!

Register now: https://www.ismp.org/node/25541

ISMP was shocked and saddened to learn the Tennessee Board of Nursing recently revoked the license of a nurse involved in a fatal medication error. This week’s ISMP free newsletter featured article presents an analysis of the process leading to the Board’s decision and calls for better ways to achieve justice, learning and improvement in patient safety: https://www.ismp.org/node/26713

Time is running out to register for ISMP's next virtual Practitioner in Residence (PIR) program on August 23-27, 2021! Benefit from an individualized development program that fosters practical ideas for organizational process and culture change; it’s a cost- and time-effective way to help solve challenges and advance your career. Participants are encouraged to bring their current medication safety issues to discuss and learn directly from nationally-recognized experts.

To learn more and to enroll, visit: https://www.ismp.org/node/25363

Read this week’s ISMP newsletter free featured article for analysis of a recently reported error where a postcraniotomy patient received contrast media via an external ventricular drain instead of an appropriate IV route during an MRI study. The article includes recommended safety steps to prevent similar errors: https://www.ismp.org/node/26401

Sign up now for the next MSOS Member Briefing webinar scheduled to be held on Thursday, July 22, 2021 from 1:00-2:00 PM ET. Register Now: https://ecri.zoom.us/webinar/register/WN_s6FpmZc2Ss6AoIIObhqrcA Short medication safety-related presentations for this webinar will include:

• Use of kits for immediate use infusions Joel Daniel PharmD, MS, CPPS Medication Safety Pharmacist Cox Health

• Specialty Pharmacy Medication Safety Challenges Jill Paslier, PharmD, CSP, FISMP Specialty Pharmacy Consultant and ISMP International Medication Safety Management Fellow

•Parenteral Nutrition Safety Issues Joe Boullata, PharmD, RPh, CNS-S, FASPEN, FACN Pharmacy Specialist Clinical Nutrition Services Hospital of the University of Pennsylvania

Read this week’s newsletter free featured article on the need to adopt dihydropyrimidine dehydrogenase (DPD) enzyme deficiency screening before the administration of fluoropyrimidine chemotherapy. The article argues that although the incidence is relatively low, patients who have it are unable to metabolize these drugs and can suffer severe toxicity and even fatal adverse reactions: https://www.ismp.org/node/25779

Surgery sites now have more time to participate in the ISMP Medication Safety Self Assessment for Perioperative Settings! The data submission deadline has been extended to October 1, 2021. Don’t miss this opportunity to evaluate your medication use systems, identify challenges, and document regulatory compliance. Visit www.ismp.org/node/18027 to access the assessment workbook.

Read this week’s newsletter free featured article for analysis of a tragic error after a discontinued fentaNYL infusion was left attached to a patient. The article includes ISMP’s safe practice recommendations to prevent similar errors: https://www.ismp.org/resources/leaving-discontinued-fentanyl-infusion-at...

Read this week’s newsletter free featured article for an analysis of a recent report of a medication containing D&C red #33 almost being dispensed to a patient with a red dye allergy. The article includes ISMP’s safe practice recommendations: https://www.ismp.org/resources/identifying-color-additives-regulated-dru...