The following are excerpts from the newsletter
- Loud wake-up call: Unlabeled containers
lead to patient's death
- SR and XL confusion continues: Budeprion SR, although
labeled extended release, is in fact generically equivalent
(AB Rated) to the sustained-release product, Wellbutrin
- Storing and dispensing nitroprusside in original packaging
can prevent mix-ups with similar looking vials.
- Loopy handwriting can lead to errors: The loop from a
letter q causes "Insulin N 14 units" to look like
"Insulin N 94 units".
- New packaging and labeling for BICILLIN products: To help
distinguish between the products, the background colors
for the C-R cartons have been changed from and the reminder
statement "NOT FOR THE TREATMENT OF SYPHILIS'' has
been added in bold, capital letters to the front, back,
and one side panel of both the Bicillin C-R and Bicillin
C-R 900/300 cartons. Also, warnings have been added to emphasize
the administration of these medications by IM injection
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- Fatal gas line mix-up: How to avoid
making this "gastly" mistake
- 2004 ISMP CHEERS for medication
safety: Celebrating excellence
- Special Announcement
ISMP teleconference. Please join us for the first in
a series of ISMP teleconferences in 2005, Meeting the
2005 National Patient Safety Goals Challenge: Avoiding dangerous
abbreviations and errors caused by look-alike drug names.
The teleconference will be held on Friday, February 4, 2005,
from 1:30-3:00 p.m. (EST). Robert Catalano, MD, MBA, and
Timothy Lesar, PharmD, from Albany Medical Center, will
discuss their involvement in a successful, collaborative,
medical staff-driven effort to eliminate error-prone abbreviations
with a regional group of NY hospitals. ISMP President, Michael
Cohen, RPh, ScD, will also discuss the November 2004 National
Summit on Medical Abbreviations, convened by the Joint Commission
and the American Medical Association to explore the scope,
implications, and difficulties of complying with the Joint
Commission's "minimum list" of dangerous abbreviations.
Using real-life examples from error reporting programs,
Dr. Cohen will also explore the vulnerabilities of look-alike
and sound-alike drug names and discuss various ways to reduce
the risk of errors with these products. Slides and handouts
will be provided before the teleconference, and continuing
education credit will be available for nurses and pharmacists.
cleaning and maintenance is key for preventing errors with
faxed medication orders.
(ipratropium/albuterol) demonstration containers could be
mistaken for the actual product.
miss with Dakin's solution serves as a reminder about proper
labeling and storage of irrigation solutions.
- 7th annual
ISMP CHEERS for medication safety awarded to organizations
and individuals at the ASHP Midyear Clinical Meeting last
recognition: The 2004 ISMP Medication Safety Alert! clinical