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The following are excerpts from the newsletter

April 8,1998

  • Should disciplinary action be taken against those who make multiple or catastrophic errors?
  • Reducing medication errors becoming a priority for FDA and pharmaceutical industry
  • Safety Briefs
    • Ambulatory care practitioners should exercise caution when using estrogen/progestin combinations now that Wyeth-Ayerst has added an additional combination with a different strength of the progestin.
    • Possible confusion between Testoderm® with Adhesive and Testoderm TTS®?
    • Ticlid® use has been linked to thrombotic thrombocytopenic purpura.
    • Physician ordered generic kaolin/pectin as "Kaopectate® 30 mL via NG tube prn for loose stools". Nurse transcribes the order as Kayexelate. Since the order included an indication the error was caught.
    • . There is no clear separation of nontoxic, toxic, and lethal doses of colchicine. Make sure staff understands the maximum doses.
    • Reader suggests that orders requiring a decimal point be written like a check to prevent errors. For example an order for 1.4 mg would be written as one and four tenths mg in parenthesis so that it would be harder to confuse as 14 mg.
    • Application deadline for the Bridge Medical Medication Safety Management Fellowship at ISMP is April 30, 1998

April 22,1998

  • IV pump set free-flow: When is enough enough?
  • Agenda Items from January - March 1998 ISMP Medication Safety Alert!
  • Safety Briefs
    • Trissel's Handbook of Injectable Drugs 10th edition now has caution statement about the potential for fatal hemolysis and acute renal failure due to the reduction in tonicity when sufficient sterile water is used as a diluent for albumin.
    • USP currently requires specific caution labeling with the vinca alkaloid products vincristine (Oncovin®) and vinblastine (Velban®). These two products require warning labels on extemporaneously prepared syringes that state "FATAL if given intrathecally. FOR IV USE ONLY." In addition, the syringe must be placed into an overwrap (accompanies manufacturer's container) which also has this labeling. However, the package insert for vinorelbine (Navelbine®), the other vinca alkaloid available in the United States, requires only a warning label that states "FOR IV USE ONLY." Although the mechanism of toxicity for vinca alkaloid products administered intrathecally has not been clearly defined, autopsies on patients who received fatal doses of intrathecal vincristine have demonstrated vast CNS tissue necrosis and damage consistent with the dose limiting neurotoxicity for all the vinca alkaloids. To date, no cases of intrathecal administration of vinorelbine have been reported. To prevent this from happening, we recommend that all extemporaneously prepared syringes of vinca alkaloids, including vinorelbine, be treated identically with label warnings and packaging to act as barriers against intrathecal administration. Such labels and overwraps are available in the packaging of vincristine products. This concern has been forwarded to the USP and FDA for review and action to require consistent warning labels on all vinca alkaloid products
    • FDA's Center for Devices and Radiological Health is holding a live satellite video conference, "Natural Rubber/Latex Allergy: Recognition, Treatment, and Prevention" on May 5, 1998 from 1:00 to 4:15 p.m. EDT. A list of viewing sites is posted on the World Wide Web at, and a conference brochure can be ordered through the FDA fax-on-demand system by calling 800-899-0381; push 1, 2, and 37

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