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The following are excerpts from the newsletter

December 13, 2000

  • Art imitates life! Error portrayal really happened
  • The year 2000 at a glance: ISMP's medication safety "Cheers"
  • Safety Briefs
    • USP holds press conference to release the "Summary of 1999 Information Submitted to MedMARx; A National Database for Hospital Medication Error Reporting."
    • A managed care pharmacist was asked to review an appeal for CLOMID (clomiphene), which was rejected by an HMO's standard pharmacy benefit program. In reviewing the case with an appeals nurse, it was learned that the medication was being prescribed to treat premenstrual dysphoric disorder. After further review and discussion with the prescribing nurse practitioner, it was discovered that the intended medication was actually SARAFEM (fluoxetine) which was misheard as SEROPHENE (clomiphene) when the prescription was ordered by phone.
    • According to the latest JC Sentinel Event Alert (November 30, 2000), surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JC) will begin to inquire about health care organizations' use of infusion pumps without free-flow protection.
    • Mead Johnson Nutritionals has been promoting SUBDUE, a ready-to-use, flavored, peptide-based elemental liquid formula for the dietary management of patients with impaired gastrointestinal function. In one hospital the prescriber's handwriting made "Subdue" look like "sotalol" and "8oz" look like "80 mg." Sotalol is BETAPACE, which is a beta-blocker

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