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The following are excerpts from the newsletter

August 12,1998

  • What's being done to prevent look-alike and sound-alike product names?
  • Competence and experience not enough to stop errors
  • Safety Briefs:
    • Sadly, this past week there was another reported death stemming from improper pharmacy dilution of albumin.
    • Please check to see if you have in stock chromic chloride (4 mcg/mL) 10 mL vials and neostigmine methylsulfate 1:1000 (1 mg/mL) 10 mL vials, both manufactured by American Regent Laboratories. In the past, both vials had a remarkably similar color combination of gray flip-off caps and labeling that led to stocking errors.
    • American Regent also told us they've corrected a problem involving an error in the official package insert for acetylcysteine solution, USP.
    • In the past, we've warned about mix-ups between lipid-based doxorubicin and conventional doxorubicin, as well as between lipid-based amphotericin B and conventional amphotericin B. Now we've also learned about a mix-up between DaunoXome® (daunorubicin citrate liposome injection) and conventional daunorubicin.
    • Sometimes we take for granted that patients fully understand our instructions. We assume that what is obvious to us is obvious to them, so we omit discussing routine details of proper medication use.
    • Instructions for preparing Pfizer's new IV quinolone, TrovanÒ (alatrofloxacin mesylate), state that the drug is compatible with D5W, 0.45% NSS, D5 in 0.45% NSS, D5 in ¼ NSS, or D5 in LR (Lactated Ringer's). What it does not say is that it is incompatible with 0.9% sodium chloride injectio

August 26,1998

  • An overview of herbal medicines and adverse events
  • Medication errors with oxycodone products
  • Unrecognized, excessive dose of nortriptyline
  • Safety Briefs:
    • After continuing to receive reports of renal failure associated with Vistide® (cidofovir injection) use (ISMP Medication Safety Alert! November. 20, 1996), Gilead Sciences, Inc. has distributed a letter to healthcare professionals to reinforce the importance of adhering to specific treatment guidelines when administering the drug.
    • The Special Alert! we sent last Wednesday evening was prompted by another report of a serious medication error involving confusion between lipid-based and conventional amphotericin B. The latest error involved a 17-year-old post-bone marrow transplant patient who developed fungal sepsis while hospitalized.
    • In our June 3, 1998 issue, we wrote about accidents involving misinterpretation of the total amount of drug in Cerebyx® (fosphenytoin) and Ketalar® (ketamine) vials labeled by Parke-Davis.
    • Follow-up to last issue's safety brief on Trovan®: Pfizer contacted us last week to confirm that the reason 0.9% sodium chloride injection isn't mentioned as a compatible diluent for Trovan is because they observed a precipitate in admixtures.
    • The session, "Working to prevent medication errors: Lessons from Denver," presented this past June at the ASHP Annual Meeting in Baltimore, will be repeated at the ASHP Midyear Meeting in Las Vegas on Monday, December 7, 2-5 PM.
    • Don't overlook our medication safety posters as a way to help spread the word about medication safety during Pharmacy Week in October. Thirteen color posters depict various prescribing problems, suggest improvement methods, and are ideal for pharmacy displays or posting on nursing unit bulletin boards, in doctor's lounges, in the pharmacy, etc. They also can be used as part of the hospital's quality improvement process. To order posters, call 215 947 7797
    • A search engine has been added to our web site ( to help readers locate articles from all past issues of the ISMP Medication Safety Alert! This supplements the annual index

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