The following are excerpts from the newsletter

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August 8, 2001

• It's time for a new model of accountability.
• Hazard Warning - Look-alike containers of NIMBEX (cisatracurium besylate) injection.
• Other full stories in this week's issue.

  • A tragic lab-related error at a Pennsylvania hospital resulted in incorrect INR (International Normalized Ratio) calculations for 932 patients. As many as five deaths may be related.
  • Another error due to confusion between LENTE (insulin zinc suspension) and LANTUS [insulin glargine (rDNA origin)] insulins.

  

  • Congratulations to the 2001 recipients of the Pinnacle Awards! The award recognizes contributions to healthcare quality with the use of medications. This year's winners include Lucian L. Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health. (Individual category); Sentara Healthcare, Norfolk, VA (Voluntary Health Agency/Non-profit Organization/Government Agency/Association category), and The Eckerd PatientCARE Network, Largo, FL (Group Practice/Health System/Corporation category). The Pinnacle Awards are presented by the APhA Foundation Quality Center and the Health Care Quality Alliance.
  • ISMP has issued a warning about confusing argatroban labeling. The top flap of the vial carton reads "100mg/mL" but there is a 2.5 mL, 250 mg vial in the carton. Will someone get an overdose?
  • RECOMBIVAX HB (hepatitis B vaccine) accelerated dosing schedule may lead to errors
  • DEPAKOTE ER error reports still arriving at ISMP
  • The Pharmacy Society of Wisconsin has recently published "Medication Use Practice Standards to Maximize Patient Safety."
    

August 22, 2001

• ISMP survey on perceptions of a nonpunitive culture produces some surprising results
• Hazard Alert! - Asphyxiation possible with syringe tip caps. Do not provide hypodermic syringes to parents for administering oral liquids to children.
• Main article: back page
  The recent admission of a Kansas City community pharmacist that purposely diluted chemotherapy for financial gains suggests the need for new outpatient standards for sterile compounding of injections and quality control measures.
• Safety Briefs:
• Some women became pregnant while taking Accutane because they did not understand the teratogen warning symbol on the package and they had not been counseled.
• No charges will be filed against a Michigan nurse who allegedly gave undiluted potassium phosphate injection concentrate intravenously.
• Continuing mix-ups reported between OxyContin (oxycodone HCl controlled-release tablets) and oxycodone HCl immediate release tablets. From August 26, 1998 issue
• Errors possible with Risperdal oral solution because it is packaged with a foreign-manufactured oral syringe that has a volumetric scale that runs in reverse of common US syringes.



• Special announcements:
• Join us at the Academy of Managed Care Pharmacy 2001 Educational Conference in Dallas for an ISMP pre-conference dinner symposium, "Straight Talk about Computerized Prescribing" on October 17, 2001, from 3 p.m. to 7 p.m. at the Hyatt Regency Hotel. Call 215 947 7797 to reserve your spot.
• We are seeking nominations for the 4th Annual ISMP Cheers Awards. Let us know if you are aware of an individual, a hospital, health system, or company that has done something extraordinary in the area of medication safety this past year so that they can be considered for this nationally recognized award. A travel stipend will be provided to awardees to attend the award dinner on December 4, 2001, during the annual ASHP Midyear Clinical Meeting in New Orleans.
• ISMP is pleased to provide the ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacies, which is available as a PDF file for downloading so pharmacies can begin the self-assessment process now. Later, instructions will be provided for submitting data to ISMP and obtaining scores for comparison to demographically similar community or ambulatory care pharmacies. We hope that all the nation's pharmacies will participate!
• 4th Annual ISMP Cheers Awards Dinner