The following are excerpts from the newsletter
- Pain, paralysis, and
knowledge of impending death marks intrathecal vincristine
- ISMP Quarterly Action Agenda:
January - March 2000
- Safety Briefs
- Some respiratory therapy drugs are packaged in disposable,
clear plastic containers with raised embossed labels
that are difficult to read. Whenever possible, consider
using equivalent products from a different manufacturer
with easy-to-read, printed labels.
- Re-use of a family member's prescription vial lead
to patient getting the wrong medication. Remember to
advise patients to discard empty prescription vials
and to never store multiple drugs in the same container.
- As part of our partnership with the American Hospital
Association, ISMP has developed a tool for US hospitals
to assess safe medication practices in each facility,
identify opportunities for improvement, and compare
experiences with the aggregate experiences of demographically
similar hospitals. The ISMP® Medication Safety Self-AssessmentT,
which has been endorsed by a number of major health
care organizations, will be mailed to pharmacy directors
in all US hospitals in late April.
- Health professionals/dialysis clinicians were recently
notified about problems with using single use only EPOGEN
(epoetin alfa) vials for multiple use.
- ISMP has elected three new members to its Board of
- Hospital survey shows much
more needs to be done to protect pediatric patients from
- Single name for drugs may increase confusion
- Safety Briefs
- Hazard Warning - New packaging has created a problem
with METHERGINE (methylergonovine maleate) injection
and BRETHINE (terbutaline sulfate) injection.
Picture of new packaging
- A potential for confusion exists between LEVAQUIN
(levofloxacin) 250 mg and 500 mg premixed minibags once
the containers are removed from their overwraps.
- What constitutes a safe prescription workload for
pharmacists working in an ambulatory care pharmacy?
- We applaud Abbott Laboratories for recently changing
a product label to improve safety. Last week, FDA approved
a revision, proposed by Abbott, to redesign and recolor
the metoclopramide box and eliminate use of the "rocket
stripes" that were inherited from Sanofi. Picture
of both the old and new packaging is available.
- ISMP is accepting applications for the 2000-2001 Safe
Medication Management Fellowship until May 15, 2000.
The one-year fellowship program trains a nurse, pharmacist,
or physician, who has at least one year of clinical
experience, in methods for preventing medication errors.
The fellow works closely with ISMP staff on educational
activities and visits practice sites, regulatory agencies,
and pharmaceutical manufacturers throughout the US.
Call us at 215-947-7797 for a syllabus and application.
- National Nurses Week is May 6-12, 2000. Help celebrate
by promoting medication safety issues with ISMP's colorful
- The British Medical Journal published a theme issue
on March 18, 2000, about medical errors. A number of
excellent articles explore the causes, costs, and "potential
remedies" of medical errors (http://www.bmj.com/content/vol320/issue7237/#TWIB).
A link is also available at the ISMP web site.