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April 6, 2006

  • IV potassium given epidurally: getting to the “route” of the problem
  • ADR Prevent-ERR: Preventing renal failure from contrast media

    Radiocontrast-induced nephrotoxicity is one of the leading causes of hospital-acquired acute renal failure. Learn about risk factors and guidelines for prevention.
  • APP label needs clarity

    Confusion has resulted from the way American Pharmaceutical Partners’  (APP) adenosine injection vial is labeled.
  • Rapid insulin infusion

    A diabetic patient received an insulin infusion at too rapid a rate while in radiology.
  • Wanted–new name

    The brand name OxyQD (oxycodone) could cause significant overdoses.
  • Textbook errata and note about AGGRASTAT (tirofiban)

    Corrections are needed in the Mosby’s Nursing Drug Reference from the years 2001 through 2006.
  • Names too much alike

    A near mix-up reported between the brand name TROPHAMINE (10% amino acid solution) and tromethamine (THAM).

Special Announcements…

  • ISMP Survey on Medication Reconciliation

    Please participate in our survey! ISMP is interested in knowing how you are progressing with the Joint Commission’s National Patient Safety Goal requiring medication reconciliation. Please take a few minutes to complete the short survey at:
  • Nominations for Cheers Awards

    The ISMP Board of Trustees invites you to nominate Individuals or Small Groups, Healthcare Organizations, or Professional Organizations/Group Collaboratives for this year’s annual ISMP Cheers Awards. The nominees must have achieved extraordinary success in the area of medication safety in the prior 12 months. Nominations are also being accepted for the annual ISMP Medication Safety Alert! Subscriber Award, which honors an organization that widely distributes and uses ISMP newsletters to improve medication safety. Self-nominations are welcomed. All nominations must be received by August 15, 2006. Award recipients will be recognized at our annual Cheers Awards banquet, to be held in Anaheim, CA on December 5, 2006. Click here for more information.

April 20, 2006

  • Original document needed to scan orders to pharmacy
  • Morphine concentrate in plastic ampuls.
  • ISMP has received several reports regarding the packaging of morphine sulfate immediate release, concentrated oral solution (20mg/1mL).  This product is manufactured in a plastic ampul that does not bear any markings and could lead to errors.

  • FDA calls for medical gas tank changes.
  • A proposed rule requires connectors on portable cryogenic medical gas containers to be attached to the cylinder body in such a way that only the tank’s manufacturer can remove the fittings.

  • Quarterly Action Agenda:  January – March 2006
  • ISMP has developed a selection of agenda items and actions to reduce the risk of medication errors at your practice site.  The Action Agenda is presented in a “to do” list format, summarizing each problem, highlighting ISMP recommendations, and providing space for the organization to assess the needed actions, assign tasks, and note completion dates.

****CORRECTION NOTICE! In the Quarterly Action Agenda of the April 20, 2006 issue of the ISMP Medication Safety Alert! (page QAA 2) incorrectly described a “code bug” with the Abacus TPN Software. The error concerns vitamin K, NOT potassium. The original article in our March 9, 2006 issue contains correct information. Click here for the text of the March 9th article. We will be printing a correction in the upcoming May 4th newsletter. The text in the link above has been corrected. We apologize for the mistake.****

Click here to download a corrected replacement page.

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