The following are excerpts from the newsletter
- "Cheers" for
medication safety: Celebrating those who made a difference
- A holiday gift for you and your patients: Pathways
for Medication Safety - We are proud to announce that,
through support of the Commonwealth Fund and input from
a distinguished advisory panel and evaluation hospitals,
an extensive set of coordinated tools, known as Pathways
for Medication Safety, is now available, free of charge.
They can be downloaded from
- Safety Briefs
- The American Heart Association (AHA) issued a scientific
statement, "Medication Errors in Acute Cardiac
Care," in the November 12, 2002, issue of its journal,
- ISMP announces the availability of a full-time fellowship
position beginning this summer at our office in Huntingdon
Valley, PA (near Philadelphia). The ISMP Safe Medication
Management Fellowship trains a health professional with
at least one year of clinical experience. Call 215-947-7797
or email us to
to request a syllabus and application form for the programs.
- The ISMP Medication Safety Alert! will not be published
during the holiday season. Beginning January 9, 2003,
publication will occur on alternate Thursdays. Look
for a new PDF format and appearance.
- Two excellent medication safety videotapes are now
available through ISMP. Bridge Medical recently announced
that it has donated exclusive distribution rights to
the award-winning documentary, Beyond
Blame, to ISMP. Beyond Blame's case histories
of a pharmacist, a nurse, and a physician -- each who
has been involved in a fatal medication error -- demonstrate
the impact of medication errors on clinicians and patients
and the need to understand the system-based causes of
errors. A new video, Building
System Safeguards for the Safe Use of High-Alert Medications
also is available through ISMP. This video was produced
as one of the tools for the Delaware Valley (Philadelphia
area) Regional Medication Safety Program for Hospitals.
Its focus is on safeguards that hospitals can employ
in their medication systems (ordering, storage, preparation,
dispensing and administration) to prevent errors with
high-alert drugs. For more information, call 800 FAIL
SAFE or visit www.ismp.org .
- Warning! Prevent mix-ups between vaccines and
neuromuscular blockers. Several weeks ago, an inexperienced
nurse in Taiwan accidentally administered atracurium
instead of hepatitis B vaccine to seven infants.
- ractitioners whove been involved in implementation
and maintenance of computerized prescriber order entry
(CPOE) at their institutions recently have identified
some important pitfalls. The lessons learned have been shared through a computer listserve coordinated
by pharmacist Toby Clark, former director of pharmacy
and faculty member at University of Illinois, Chicago.
ISMP and ASHP have been asked to alert clinicians
to its existence. You can find this list of issues
on our website.
Operation of the listserve was recently transferred
to ASHP where Mr. Clark will continue to coordinate
it. ASHP members can join the listserve at: https://shop.ashp.org/timssnet/login/tnt_login.cfm?redirect=LISTSERV.
Non-ASHP members who are interested in joining should
e-mail Mr. Clark.