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August 11, 2005

• New fentanyl warning: more needed to protect patients
  
• Wrong patient error
  An oncology patient received another patient’s chemotherapy despite verification by two nurses before administration.
  
• Units, mg, or mL?
  Using an insulin syringe to measure the dose of non-insulin medications can lead to confusion between international units and mg.
  
• Depo-subQ provera 104
  A recently marketed medroxyprogesterone acetate suspension may lead to errors.
  
• More on Baxter pump recall.
  
• Message in our mailbox.
  A physician wrote in response to our recent article on expiration dates to let us know that an international standard exists for expressing dates.
  

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August 25, 2005

• Safety still compromised by computer weaknesses
  Comparing 1999 and 2005 pharmacy computer field test results
  
• Vaccine mix-up
  Look-alike packaging of the adult and pediatric strengths of hepatitis B vaccines can lead to errors.
  
• Apologies gain momentum.
  Healthcare executives, insurers, and physicians have begun to fully embrace disclosure and apologies when medical errors occur.
  
• Textbook errata
  Lexi-Comp has informed ISMP of a dosing error in its 2005-2006 Drug Information Handbook (13 th edition) for irinotecan (CAMPTOSAR).
  

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