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February 6, 2002

• "Smart" infusion pumps join CPOE and bar coding as important ways to prevent medication errors
• Clinicians often unaware of colchicine dose limits
• Safety Briefs
  • Many reference texts and drug information databases contain incomplete dosing recommendations for IV colchicine. Unfortunately, some patients have died after as little as a 7 mg cumulative dose. If prescribed, the order should indicate a specific stop time and reflect that 4 mg/week should not be exceeded.
  • A recent incident shows how drug information leaflets handed to patients can help prevent errors.
  • Caution: The directions for use of CETACAINE (benzocaine, tetracaine, butamben) topical spray are prone to misinterpretation and could result in patient harm. An ambiguous statement on one of the container label panels might mislead practitioners to spray continuously for a minute when spraying in excess of two seconds is contraindicated. The manufacturer is revising the statement.
  • A nurse falsified the records about a medication error to show that a patient was properly treated when he wasn't. The patients died later during the month and court records tied the death to the error. Now, this nurse - the first in the state of Pennsylvania since enactment of a 1996 statute - will spend the next ten years in a federal prison for falsifying medical records.
  • The term "IV bolus" is ambiguous when rate of injection isn't expressed. Such ambiguity has been tied to patient harm when certain substances are given too rapidly.
  • As effective as computerized prescribing is in reducing medication errors, some new types of errors may be created. Two examples are given.
  • Announcement: A special 1 ½ hour teleconference on failure mode and effects analysis (FMEA) will occur on February 20, 2002, at 2 p.m. EST. See www.ismp.org for details about the program, which includes presentations by speakers from ISMP, the VA Center for Patient Safety, and JC. Register at www.ismp.org or 215-947-7797.

February 20, 2002

• Eliminating dangerous abbreviations and dose expressions in the print and electronic world
• Hazard Alert! Recurring confusion between tincture of opium and paregoric
• Safety Briefs
  • In this week's issue, read about a bone marrow transplant patient who became hyperkalemic after getting NEUTRA PHOS K (14.25 mEq of potassium) instead of the ordered K PHOS NEUTRAL (1.1 mEq potassium)
  • A hematologist who was treating the patient post-operatively gave the surgeon a telephone order to start argatroban (a direct thrombin inhibitor) 2 mcg/kg/minute. The surgeon mistook the order as ORGARAN (danaparoid) 2 units/kg/minute.
  • The following drug name mix-ups were also included in our Safety Briefs section this week: TICLID (ticlopidine) confused with TEQUIN (gatifloxacin); REMINYL (galantamine hydrobromide) with ROBINUL (glycopyrrolate); and HYDROGESIC (5 mg hydrocodone bitartrate with acetaminophen 500 mg) with hydroxyzine.
  • ISMP welcomes two new professional staff members. Mary Kate Kelly, PharmD, comes to us with experience in ambulatory care and as an editor and writer for medical publications. Kate's focus will be to enhance our communication of safety information to ambulatory care practitioners. Michael Donio, MPA, has extensive experience working with healthcare consumers. He served for almost 20 years as Director of Projects, People's Medical Society, a national, nonprofit organization, authoring numerous publications on consumer health care topics. He will be coordinating our efforts to reach healthcare consumers about medication safety issues.
  • Applications are now available for The American Quest for Quality Prize: Honoring Leadership and Innovation in Patient Care Quality, Safety, and Commitment. This 2002 award, supported by grants from the McKesson Corporation and McKesson Foundation, will honor hospitals that have demonstrated a culture of patient safety. The award recipient will receive $75,000. Two finalists will receive $12,500 each. Applications are due by March 1, 2002. For more information, please visit www.aha.org/questforquality .