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The following are excerpts from the newsletter

April 5, 2000

  • 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 Trustees

April 19, 2000

  • Hospital survey shows much more needs to be done to protect pediatric patients from medication errors
  • 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 Methergine & Terbutaline
      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.
  • Announcements
    • 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 posters.
    • 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 ( A link is also available at the ISMP web site.

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