1. Cohen, Michael R. ScD, MS, RPh

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New guidelines cover a range of practice settings

The Institute for Safe Medication Practices (ISMP) has revised and expanded its Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps to provide strategies for addressing potential barriers and integrating this technology with other electronic systems. The expanded guidelines cover a broad range of smart infusion pump usage in both inpatient and ambulatory settings. The expanded guidelines also include recommendations to employ smart infusion pumps with dose error-reduction systems for plain I.V. fluid infusions and provide a new set of guidelines associated with bidirectional smart pump interoperability with the electronic health record. For details on this and other ISMP safety guidelines, visit



Beware of carton confusion

Coherus BioSciences has sent an important drug warning letter regarding the potential for carton confusion between Udenyca (pegfilgrastim-cbqv) and Prolia (denosumab) due to their similar-looking cartons (see photo above). Udenyca is a leukocyte growth factor biosimilar to Neulasta (pegfilgrastim), and Prolia is a RANK ligand (RANKL) inhibitor indicated to treat osteoporosis. Similarities in the packaging of Udenyca and Prolia have been associated with dispensing and administration errors. The warning letter notes that errors could be associated with adverse events.


In the warning letter, Coherus notes that it has received two reports of patients who received Udenyca instead of the intended Prolia. One patient was hospitalized for serious adverse events including myocardial infarction. To eliminate the risk of confusion linked to look-alike packaging, Coherus is redesigning the Udenyca carton label. Read the entire warning letter at



Peel away confusion

Rocuronium is a nondepolarizing neuromuscular blocker indicated as an adjunct to general anesthesia to facilitate both rapid-sequence and routine endotracheal intubation. When checking a rapid-sequence intubation kit, a pharmacist noticed that the strength expressed on rocuronium 5 mL vials was 10 mg/mL instead of the usual 50 mg/5 mL. Upon closer inspection, the pharmacist realized that the manufacturer had added a peel-off label noting 10 mg/mL over the vial label that states 50 mg/5 mL (see photo below). The peel-off label is meant to be removed from the vial label and attached to a syringe once the drug has been drawn up. During a busy intubation scenario, someone reading the peel-off label might mistakenly assume the vial contains a total of 10 mg, not 50 mg. The pharmacy is now removing the 10 mg/mL peel-off label before dispensing the vials.


The manufacturer, Fresenius Kabi, includes additional peel-off labels in the carton with the rocuronium vials, so placing a peel-off label on the vial is not necessary. Contacted by ISMP, the manufacturer has agreed not to place peel-off labels on vials in the future and will continue to include these labels separately in the carton.

Figure. The vial on ... - Click to enlarge in new windowFigure. The vial on the left contains 50 mg/5 mL but the peel-off overlay states 10 mg per mL, which could be confused as the total amount in the vial. The vial on right has had the peel-off label removed, revealing the correct amount on the vial label. Additional peel-off labels, which are provided in the drug cartons, are shown in the lower right corner.