Post date: 1 hour 11 min ago

At the recently held MSOS Member Meeting during the ASHP Medication Safety Collaborative in Minneapolis on June 4, 2017, a member shared an occurrence that happened in their facility.  The member believed that a defect in BD’s (Pyxis) MedStation ES software resulted in the misinterpretation of an order frequency intended to be every Monday, Wednesday and Friday as every day that was associated with a patient incident. David Swenson, Vice President, Clinical Strategy, Medical Affairs, Medication Management Systems at BD attended that meeting and publicly volunteered to investigate the report. David shared his investigation For the full message with an excerpt of his findings, please click on the title above.

Post date: 1 week 2 days ago

MSOS currently has a list of list of Resource Links for Medication Safety Officers under the Resources tab of our website ( This list was developed to help new medication safety officers identify resources that they can utilize in their new position.  Knowing how rapidly things change, we would appreciate your feedback! Let us know if any new links should be added or deleted. Please email your suggestions to Darryl Rich at by no later than July 15, 2017. Thank you.

Post date: 1 week 2 days ago

MSOS is looking for volunteer members to assist ISMP in updating two of its medication safety guidelines. Based on the prevalent use of computerized prescriber order entry (CPOE) and new automated dispensing cabinet (ADC) technology, the MSOS guidelines committee has recommended that ISMP update the ISMP Guidelines on Standard Order Sets (2010) and the ISMP Guidelines on Interdisciplinary Safe Use of Automated Dispensing Cabinets (2008). MSOS members who volunteer for a task force will be responsible for reviewing the current guidelines and participating in a couple of conference calls to discuss suggested edits (including additions and deletions). ISMP will review the recommended edits and issue an updated set of guidelines. If you are interested in being on one of these task forces, please send an email to Darryl Rich at by no later than July 15, 2017 indicating which task force you would like to participate in.  Thank you. 

Post date: 1 month 1 week ago

For years, insulin has been shown to be associated with more medication error-related harm than any other drug. The new ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults are designed to help healthcare practitioners prevent errors and improve outcomes for patients with diabetes. The guidelines, based on a multidisciplinary consensus conference of experts, provide recommendations for avoiding at-risk behaviors involving subcutaneous insulin across the entire continuum of care, including prescribing, preparation and administration, monitoring, and patient education. The document also addresses evolving practices, devices, and technology that aim to enhance the safety of insulin use, such as with concentrated insulin and insulin pen devices. For a copy, visit:

The mission of the Medication Safety Officers Society (MSOS) is to advance and encourage excellence in safe medication use by providing communication, leadership, direction, and education among its members.