National Medication Error Research Articles

Evaluation of Pharmacist and Nurses Practices of IV Admixture Preparation Outside Pharmacy in Saudi Arabia

Published on:June 2022 Journal of Young Pharmacists, 2022; 14(2):244-248 Original Article | doi:10.5530/jyp.2022.14.46 Authors: Nuzhat Banu, Naher Mohammed Aldubaisi, Batool Mohammed Al Dubaisi, Mohammad Daud Ali,* Ayaz Ahmad, Yousif A M HassanDepartment of Pharmacy, Mohammad Al-Mana College for Medical Sciences, As Safa, Dammam, SAUDI ARABIA. Abstract: Background: Compounding and dispensing sterile preparation is a major part of pharmacy practice and the responsibility of pharmacists. The intravenous admixtures are sterile products prepared by mixing a medication or a combination of medications with a different intravenous solution. Errors during IV preparations have been reported to ISMP national medication error reporting program and are regularly discussed. Methods: An online survey-based, descriptive, cross-sectional study was conducted among Pharmacists and nurses working in Eastern Province, Saudi Arabia. The questionnaire was distributed among pharmacists and nurses compounding IV admixtures in the hospitals. Results: Out of 206, 115 (55.8%) respondents reported preparing IV admixtures outside pharmacy out of which 79 (68.7%) prepared it daily. Maximum were IV infusions. 63 (54.8%) of them prepared more than one IV admixture at one time. Although there were a high number 93 (80.8%) of people who said that they were provided with the established guidelines for preparing IV admixtures outside pharmacy however there is enough number 16 (13.9%) who said that they were not aware of them. Antibiotics 93 (80.8%) were frequently prepared in the form of IV admixtures. 22(19.1%) respondents reported experiencing errors during preparing IV admixtures. Use of wrong dose, concentration, diluent, diluent volume 12 (54.54%) was the most frequent error reported. Rushing during an emergency was the main challenge 56 (48.7%) faced. Conclusion: Although great emphasis is made to prepare the most IV preparations inside the pharmacy still there are situations where many IV medications had to be prepared outside the pharmacy. Intravenous infusions, antibiotics were the most commonly prepared IV admixtures. The most common error reported was in preparing the dose which could be due to the rushing during emergencies. Our study suggests that proper IV admixture training during the course study and on job must be made mandatory and wherever possible ready to use IV injections must be used.Key words: IV Admixture, Outside Pharmacy, Pharmacist, Nurses, Saudi Arabia.

Medication error awareness among health care providers in Palestine: A questionnaire-based cross-sectional observational study

BackgroundIncreased awareness among healthcare professionals regarding medication errors and the establishment of a medication error reporting system can significantly reduce the prevalence of medication errors. Unfortunately, Palestine lacks a regulatory system for the control, reporting, and education of medication errors. ObjectivesThis study aimed to assess the awareness of medication errors and reporting of medication errors in the Palestinian medical community. MethodsA cross-sectional observational study was conducted using a self-administered survey involving doctors, nurses, and pharmacists in Palestine. The survey consisted of 20 questions to assess healthcare providers' awareness and course of actions related to medication errors. Data were collected from February 2020 to April 2020. Statistical Package for the Social Sciences (SPSS) was used for data analysis. This study was approved by the ethical committee of Birzeit University. ResultsA total of 394 participants were included, including 202 nurses, 114 doctors, and 78 pharmacists. 203 (51.5%) had a good awareness level of medication errors, whereas 126 (32%) and 65 (16.5%) had average awareness and poor awareness levels, respectively. In addition, 66.0% of providers did not inform the patients after recognizing the error. Fear of legal or social consequences and being too busy are significant barriers to reporting medication errors. Moreover, 35 % of all providers were not aware of the reporting system in their institutions or the reporting methodology, and only 26% of all participants confirmed that their institutions provided continuous education on medication errors. ConclusionThis study revealed differences in healthcare professionals' awareness of medication errors. The study's findings emphasize the urgent need to adopt appropriate measures to raise awareness about medication errors among healthcare providers in Palestine. Furthermore, establishing a regulatory policy and a national medication error reporting system to improve medication safety.

National medication errors project shows reduction in hazardous prescribing

National medication errors project shows reduction in hazardous prescribing

National Medication Errors Reporting System at Ministry of Health in Saudi Arabia

National Medication Errors Reporting System at Ministry of Health in Saudi Arabia

Student observations of medication error reporting practices in community pharmacy settings.

Medication safety practices and methods for reporting errors in community pharmacies are relatively unknown. (s): The primary objective of this study was to describe student-reported data on medication safety and error reporting practices in community pharmacies, and secondarily describe student learning from this assignment. Second professional year pharmacy students enrolled at Purdue University College of Pharmacy in the United States observed and recorded medication safety and error reporting practices as part of an experiential assignment. Data were collected from 170 unique pharmacy settings between the years 2016-2018 and analyzed using descriptive statistics and a paired t-test to assess student learning. 51% of students reported documentation of 1-10 errors or near misses annually, with an additional 30% reporting 11-30. Near misses were only reported 26% of the time. Errors were most commonly reported to a pharmacy-specific reporting system (84%) and the Institute for Safe Medication Practices National Medication Errors Reporting Program (84%). The most frequently reported error types included wrong directions (34%), wrong drug (14%), wrong strength (13%), and wrong patient (12%). Pharmacists were observed to be interrupted approximately 19 times every hour. Anonymous error reporting was typically not allowed to the pharmacy's preferred error reporting system (71%). A policy requiring that the prescriber is contacted about errors was observed at 77% of the sites. The most common consequences of committing an error were education/training (72%) or progressive discipline (41%). Students reported a statistically significant increase in understanding of medication safety practices and methods for reporting errors in community pharmacies. (p < 0.01). This data supplements existing literature on medication safety practices and error reporting in community pharmacy settings, as well as highlights knowledge gaps outside the scope of this study.

Multifactorial Causes of Tacrolimus Errors: Confusion With Strength/Formulation, Look-Alike Names, Preparation Errors, and More Ensuring Safety of Recipes for Drug Compounding Please, no more teaspoon dosing.

A recent string of errors associated with tacrolimus, an immunosuppressant used primarily to prevent rejection in transplant recipients, prompted ISMP to review the literature and analyze related events reported to the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) and the ISMP National Medication Errors Reporting Program (MERP). We found that tacrolimus has been involved in many reported errors during the past decade that have been caused by a wide variety of factors, the most common of which are described below.

Alignment with the ISMP 2018–2019 Targeted Medication Safety Best Practices for Hospitals

Despite the great strides in medication safety and the plethora of new medication-related technologies and devices in the United States over the last few decades, thousands of medication errors are still occurring each year. 1 Institute for Safe Medication Practices (ISMP) National Medication Error Reporting Database. in: Confidential Access. 2017 Google Scholar Unfortunately, with new innovation also come new sources of error. 2 Institute for Safe Medication Practices Understanding human over-reliance on technology. in: ISMP Medication Safety Alert!21 (18). 2016: 1-4 Google Scholar , 3 Lawes S Grissinger M Medication errors attributed to health information technology. PA-PSRS Patient Saf Advis. 2017; 14: 1-8 Google Scholar Although it is unreasonable to believe that any complex process involving human interaction with systems (such as medication use), will ever be error free, we can feel fortunate that not all errors result in patient harm. What is regrettable, however, is the portion of these events each year that are both harmful and preventable. 1 Institute for Safe Medication Practices (ISMP) National Medication Error Reporting Database. in: Confidential Access. 2017 Google Scholar Although national reporting of medication-related events to federally recognized patient safety organizations, such as the Institute for Safe Medication Practices (ISMP), has resulted in numerous documented changes to patient safety, 4 Institute for Safe Medication Practices Historical Timeline. http://www.ismp.org/about/timeline.aspDate accessed: November 5, 2017 Google Scholar in the continued analysis of medication-related events, ISMP has found that specific preventable medication-related events resurface and continue to result in serious outcomes and even patient deaths. 1 Institute for Safe Medication Practices (ISMP) National Medication Error Reporting Database. in: Confidential Access. 2017 Google Scholar Susan F. Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP ⁎ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publication.ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publication.), Horsham, PA.

Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012)

Reporting and analysing the data on medication errors (MEs) is important and contributes to a better understanding of the error-prone environment. This study aims to examine the characteristics of errors submitted to the National Medication Error Reporting System (MERS) in Malaysia. A retrospective review of reports received from 1 January 2009 to 31 December 2012 was undertaken. Descriptive statistics method was applied. A total of 17,357 MEs reported were reviewed. The majority of errors were from public-funded hospitals. Near misses were classified in 86.3% of the errors. The majority of errors (98.1%) had no harmful effects on the patients. Prescribing contributed to more than three-quarters of the overall errors (76.1%). Pharmacists detected and reported the majority of errors (92.1%). Cases of erroneous dosage or strength of medicine (30.75%) were the leading type of error, whilst cardiovascular (25.4%) was the most common category of drug found. MERS provides rich information on the characteristics of reported MEs. Low contribution to reporting from healthcare facilities other than government hospitals and non-pharmacists requires further investigation. Thus, a feasible approach to promote MERS among healthcare providers in both public and private sectors needs to be formulated and strengthened. Preventive measures to minimise MEs should be directed to improve prescribing competency among the fallible prescribers identified.

IV Push Medication Administration: Making Safe Choices; Choosing Best Practice

It has been estimated that more than 90% of hospitalized patients receive some form of intravenous (IV) therapy. 1 Baranowski L Presidential address: take ownership. J Intraven Nurs. 1995; 18: 162-164 PubMed Google Scholar , 2 Corrigan A Infusion nursing as a specialty. in: Alexander M Corrigan A Gorski L Hankins J Perucca R Infusion Nursing: An Evidence-based Approach. 3rd ed. Saunders Elsevier, St Louis, MO2010 Google Scholar Errors involving the use of IV medications are more common than once recognized and occur in all phases of the medication use process. These errors can be particularly dangerous, depending on the drug’s properties and the complexity of its therapeutic action. Although IV push medications are clinically advantageous because of their immediate therapeutic effect, they are also challenging because of an immediate bioavailability of the administered drug, a narrow therapeutic dose range, and limitations in reversing systemic effects, all of which can contribute to harm. 3 American Society of Health-System Pharmacists Summit proceedings. Am J Health Syst Pharm. 2008; 65: 2367-2379 Google Scholar , 4 Hicks R Becker S An overview of intravenous-related medication administration errors as reported to MEDMARX®, a national medication error-reporting program. J Infus Nurs. 2006; 29: 20-27 Crossref PubMed Scopus (66) Google Scholar The significant risk for patient injury and death related to IV medication errors is well known. 3 American Society of Health-System Pharmacists Summit proceedings. Am J Health Syst Pharm. 2008; 65: 2367-2379 Google Scholar , 4 Hicks R Becker S An overview of intravenous-related medication administration errors as reported to MEDMARX®, a national medication error-reporting program. J Infus Nurs. 2006; 29: 20-27 Crossref PubMed Scopus (66) Google Scholar , 5 Aspden P Wolcott JA Bootman JL Cronenwett LR Committee on Identifying and Preventing Medication Errors, Board on Health Care Services, Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. National Academy Press, Washington, DC2007 Google Scholar , 6 Flynn EA Barker KN Research on errors in dispensing and medication administration. in: Cohen MR Medication Errors. 2nd ed. American Pharmacists Association, Washington, DC2007: 15-41 Google Scholar , 7 Kaushal R Bates DW Landrigan C et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285: 2114-2120 Crossref PubMed Scopus (1379) Google Scholar , 8 Ross LM Wallace J Paton JY Medication errors in paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000; 83: 492-497 Crossref PubMed Scopus (262) Google Scholar , 9 Institute for Safe Medication Practices Institute for Safe Medication Practices National Medication Errors Reporting Program Database. Institute for Safe Medication Practices, Horsham, PA2015 Google Scholar The Institute for Safe Medication Practices (ISMP) has received and published numerous IV push–related error reports involving patient injury obtained through its National Medication Errors Reporting Program. 9 Institute for Safe Medication Practices Institute for Safe Medication Practices National Medication Errors Reporting Program Database. Institute for Safe Medication Practices, Horsham, PA2015 Google Scholar Susan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP 1ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention.1ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.) Michelle Mandrack is Director of Consulting Services, Institute for Safe Medication Practices, Horsham, PA.

The Institute for Safe Medication Practices and Poison Control Centers: Collaborating to Prevent Medication Errors and Unintentional Poisonings.

This article provides an overview on the Institute for Safe Medication Practices (ISMP), the only independent nonprofit organization in the USA devoted to the prevention of medication errors. ISMP developed the national Medication Errors Reporting Program (MERP) and investigates and analyzes errors in order to formulate recommendations to prevent further occurrences. ISMP works closely with the US Food and Drug Administration (FDA), drug manufacturers, professional organizations, and others to promote changes in package design, practice standards, and healthcare practitioner and consumer education. By collaborating with ISMP to share and disseminate information, Poison Control centers, emergency departments, and toxicologists can help decrease unintentional and accidental poisonings.

Shock, awe, action: Learning from external errors

Shock, awe, action: Learning from external errors

Taking Another Look at Independent Double Checks

Organizational safety initiatives commonly focus on the prevention of error 1. Institute for Safe Medication Practices. ISMP National Medication Error Reporting Program (confidential database accessed July 2, 2013). Horsham, PA: Institute for Safe Medication Practices. Google Scholar ; however, as long as human beings are an intricate part of the health care equation, errors will continue to happen. Equally important, therefore, are efforts focused on detecting errors before they reach the patient and thus mitigating any harm that might result from the error. Although some errors are the result of a simple slip or lapse, most errors can be traced back to a number of complex system design and human factor causes. Addressing these varied contributory factors often requires a number of system-based strategies to prevent the error from reaching the patient or causing harm. Susan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP*), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention.

Principles for designing a safer medication label

Health literacy is increasingly seen as a patient safety issue. Patients with lower health literacy more often take prescription medications without fully understanding the instructions on the drug labels, according to one recent study.1

National and Local Medication Error Reporting Systems—A Survey of Practices in 16 Countries

To explore the existence and characteristics of national and local medication error reporting (MER) systems and to describe national medication safety experts' perceptions of a good and effective MER system and barriers to reporting. In a descriptive cross-sectional study, 32 medication safety experts were identified through member organizations of the International Pharmaceutical Federation in 88 countries and other professional organizations in 3 additional countries. These experts were invited to participate in an online survey. Sixteen national medication safety experts from different countries participated in the study (response rate, 50%). A national (n = 5) or local (n = 6) MER system existed in 11 of these countries. In 5 countries, no MER system existed. The most common features of the MER systems were confidentiality of the reported information and providing feedback to those involved in reporting. Most experts perceived that a good and effective MER system was characterized by the opportunity to learn from errors by those involved in reporting, having a nonpunitive approach to reporting, and ease of use. They also perceived that a blame culture, lack of time, training, and coordination of reporting were the main barriers to reporting. Blame culture, a lack of time, training and coordination of reporting continue to be the major barriers to reporting. Learning from errors and having a nonpunitive approach to reporting were thought to be the most critical features of a MER system. Difficulties in identifying national medication safety experts indicates a need for promoting international networking of medication safety experts and bodies for sharing information and learning from others.

Designing a safer medication label

Health literacy is being increasingly viewed as a patient safety issue. A 2006 study in the Annals of Internal Medicine demonstrated the relationship between lower literacy and a greater volume of prescription medications being taken without patients fully understanding the instructions on the medication labels. Health literacy is being increasingly viewed as a patient safety issue. A 2006 study in the Annals of Internal Medicine demonstrated the relationship between lower literacy and a greater volume of prescription medications being taken without patients fully understanding the instructions on the medication labels. The ability to understand prescription container label instructions is critical for safe medication use. Supplementary medication information, such as consumer medication information leaflets printed for each new prescription, may be too complex, too long, and written at a reading level unsuitable for many patients to comprehend. As a result, these materials are often ignored, making the prescription label the patient's primary, if not only, source of information about how to take their medication.■Clear prescription labeling is critical to a patient's understanding of medication use and adherence.■ISMP developed a set of guidelines for prescription packages to help prevent label misinterpretation. ■Clear prescription labeling is critical to a patient's understanding of medication use and adherence.■ISMP developed a set of guidelines for prescription packages to help prevent label misinterpretation. In 1999, the International Pharmaceutical Federation released its Statement of Professional Standards on Medication Errors Associated with Prescribed Medication, which stated that the packaging and labeling of prescribed medicines should be designed with a view to minimizing errors in selection and use. This statement contained a number of recommendations regarding how patient labels should be displayed. The 2006 Institute of Medicine report Preventing Medication Errors stated that problems with prescription drug labeling were the cause of a large proportion of outpatient medication errors and adverse drug events because patients may unintentionally misuse a prescribed medicine due to improper understanding of instructions. In response to this report, the American College of Physicians Foundation released a white paper, Improving Prescription Drug Container Labeling in the United States: A Health Literacy and Medication Safety Initiative, which set standards for an enhanced prescription container label. Standardized and thoughtful drug labeling practices need to be a part of an overall strategy to improve medication adherence and reduce inadvertent medication errors in community pharmacy practice. The Institute for Safe Medication Practices (ISMP) developed a set of guidelines for community and mail order pharmacy prescription packages to help prevent errors related to label misinterpretation. ISMP based its guidelines on an analysis of medication errors, pharmacy-generated labels, and the materials mentioned above. The packaging and labeling of prescribed medicines should be designed with a view to minimizing errors in selection and use. Highlights of ISMP's Principles of Designing a Medication Label for Community and Mail Order Pharmacy Prescription Packages include the following:■Never abbreviate drug names. Each drug field should contain a sufficient number of characters to prevent truncating drug names, whether single entity or multi-ingredient product. For example, patients may be unaware that prescription labels indicating the drug abbreviation APAP is actually acetaminophen.■Do not include the salt of the chemical when expressing a generic name unless there are multiple salts available (e.g., hydroxyzine hydrochloride and hydroxyzine pamoate). If the salt is listed as part of the name (e.g., U.S. Pharmacopeia-approved abbreviations such as K, Na, HBr, and HCl), then it should follow the drug name, not precede it (e.g., hydroxyzine HCl not HCl hydroxyzine).■Include both the brand name and the generic name on the label. If state law prohibits printing the brand name when the specific brand is not dispensed, then "used for" may be inserted before the brand name.■Include the condition for which the drug was prescribed if requested by the patient and if the condition is indicated on the prescription.■Include on the label a clearly visible second patient identifier, such as date of birth or current address.■Provide a written description of medication and a picture of medication, if possible. These guidelines may not always provide complete understanding of instructions to patients. Therefore, prescription labeling is only one part of an overall strategy to improve medication adherence and reduce medication errors. For more information, visit www.ismp.org/tools/guidelines/labelFormats/comments/default.asp. Institute for Safe Medication PracticesISMP’s National Medication Errors Reporting Program receives reports of errors,close calls, and hazardous conditions at www.ismp.org, [email protected], or 800-324-5723. ISMP’s President is Michael R. Cohen, BSPharm, MS, ScD, author of Medication Errors, 2nd edition, published by APhA and available for purchase on pharmacist.comor by calling 800-878-0729

Proper disposal of fentanyl patches can save lives

Proper disposal of fentanyl patches can save lives

Safety Advocate Sees Progress, But ‘Frustrating’ Problems Persist

Safety Advocate Sees Progress, But ‘Frustrating’ Problems Persist

China’s regional inequity in pharmacist’s drug safety practice

BackgroundThe promotion of patient safety and drug safety through promotion of pharmacist’s drug safety practice was among the most important aims of China’s health delivery system reform, but regional inequity in pharmacist’s drug safety practice was still serious in China.MethodsThe 2011 national patient safety and medication error baseline survey was carried out for the first time in China, and through analyzing dataset from the survey, this study was set up to test both China’s regional inequity in pharmacist’s drug safety practice and major influencing factors for pharmacist’s drug safety practice among different districts of China.ResultsPharmacist’s drug safety practice in regions with higher per capita GDP and more abundant medical resources was still better than that in regions with lower per capita GDP and less abundant medical resources. In all districts of China, pharmacist’s drug safety knowledge, drug safety attitude, self-perceived pressure and fatigue, hospital management quality, and hospital regulation were major influencing factors for pharmacist’s drug safety practice, while only in regions with higher per capita GDP and more abundant medical resources, hospital drug safety culture, supervisor’s work team management, cooperation atmosphere of work team, and drug safety culture of work team were major influencing factors for pharmacist’s drug safety practice.ConclusionRegional inequity in pharmacist’s drug safety practice still existed in China. In all districts of China, promoting pharmacist’s drug safety knowledge, drug safety attitude, self-perceived pressure and fatigue, hospital management quality, and hospital regulation could help promote pharmacist’s drug safety practice, while only in regions with higher per capita GDP and more abundant medical resources, promoting hospital drug safety culture, supervisor’s work team management, cooperation atmosphere of work team, and drug safety culture of work team could help promote pharmacist’s drug safety practice. And in regions with lower per capita GDP and less abundant medical resources, the link between pharmacist’s drug safety practice and hospital drug safety culture/supervisor’s work team management/cooperation atmosphere of work team/drug safety culture of work team should also be gradually established.

Allergic Reaction or Adverse Drug Effect: Correctly Classifying Vancomycin-Induced Hypersensitivity Reactions

During the past 5 years, numerous reports have been submitted to the Institute for Safe Medication Practices National Medication Error Reporting Program and to Quantros MEDMARX (an adverse drug event data repository) that described errors and adverse reactions related to vancomycin. Often confusion exists about whether these events are allergic reactions or some other type of adverse event. This confusion often is evidenced by the way the adverse event is recorded and through statements by the health care professionals indicating that the response was “not red man syndrome” or that the “patient had a similar reaction previously, but it was not documented as an allergy.” Typical examples of adverse events with intravenous vancomycin doses are described in the next section.

Parents' Role in Critical Events during a Child's Hospitalization Nplate Has a Confusing Label

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below. Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.