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The following are excerpts from the newsletter

December 18, 2002

  • "Cheers" for medication safety: Celebrating those who made a difference in 2002
  • 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 our website.
  • 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, Circulation.
    • 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 will not be published during the holiday season.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 .
    • 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 who’ve 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: Non-ASHP members who are interested in joining should e-mail Mr. Clark.

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