The following are excerpts from the newsletter
- Placing limits on drug inventory
minimizes errors with automated dispensing equipment
- Safety Briefs
- We have received multiple reports warning about the
potential for confusion with Organon's antidepressant
product REMERON (mirtazapine). The drug is available
in 15 mg and 30 mg tablets. Both strengths are packaged
in the same size boxes and containers with similar labeling.
- Thorough understanding of proper directions is especially
important when the patient receives a prescription for
alternating doses of warfarin. In two recent cases,
a patient's misunderstanding resulted in hospitalization.
- St. John's Wort, a popular herb used for depression,
may cause temporary nerve damage with sunlight exposure
(Bove GM. Acute neuropathy after exposure to sun in
a patient treated with St. John's Wort. The Lancet 1998;352:1121-1122).
- Monarch Pharmaceuticals, the company that recently
took over KETALAR (ketamine) injection from Parke Davis,
has been working on a new label designed to prevent
- Previously, we mentioned a problem with the 5 mL sterile
water vial supplied in the package with NEUMEGA (see
ISMP Medication Safety Alert, July 15, 1998). When the
product was launched last year, a suitable 1 mL vial
- Numerous errors have been reported when prescribers
order medications using decimal dosages
- Similar dosing and tablet strength for two drugs with
look-alike generic names, tiagabine (GABATRIL by Abbott)
and tizanidine (ZANAFLEX by Athena Neurosciences), increases
the potential for confusing these products.
- 1998 medication safety "CHEERS
- Not with my liver you don't!
- PLEASE! Complete the computer-users survey
- Safety Briefs
- Admixture on a nursing unit resulted in administering
the wrong drug to a patient via an epidural line. A
nurse prepared an epidural infusion for a post-partum
Cesarean section mother using two vials of gentamicin,
each 80 mg/2 mL, instead of fentanyl. Both the gentamicin
and fentanyl vials had look-alike red flip tops.
- FDA is stepping up their medication error prevention
efforts. Effective December 1, 1998, Jerry Phillips
has been named as Associate Office Director for Medication
Error Prevention in the newly created Office of Postmarketing
Drug Risk Assessment (OPDRA).
- · Caution: the graphics used on the 5 mL vial carton
label for ONCASPAR (pegaspargase) make it appear as
if the entire vial contains 750 international units
when actually, that is the per mL concentration. The
vial actually contains a total of 3,750 international
- Since its approval in November, 1997 for use in certain
patients with non-Hodgkin's lymphoma, approximately
70 cases of serious infusion-related events have been
reported with RITUXAN (rituximab) out of an estimated
12,000 to 14,000 patients that have been treated worldwide.
In eight of these reports, the outcome was fatal.
- The ISMP Medication Safety Alert! is published
25 times a year. This is the last issue until January
15, 1999, unless an urgent error advisory is necessary.
We thank our readers for making this alert system a
continued success and we look forward to working with
you during 1999.