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February 9, 2006

• Pump up the volume–Tips for increasing error reporting
• ISMP-Temple University ADR Prevent-ERRTM: IV lorazepam infusion and propylene glycol toxicity
  High-dose or long-term continuous infusions of lorazepam create the potential for propylene glycol toxicity in patients.
• Chew this over
  Manufacturers create the potential for a medication error by promoting products with items that look like the drug product but serve some other purpose.
• Same but different #1
  Add CARTIA to the list of drug names with different active ingredients outside of the US.
• Same but different #2
  Add ENTEX LA to the list of drug names with different active ingredients outside of the US.
• Confusion between two forms of “EDTA”
  A fatal mix-up occurred when a child was given edetate disodium instead of edetate calcium disodium (CALCIUM DISODIUM VERSENATE) during chelation therapy for autism.

february 23, 2006

• IV vincristine survey shows safety improvements needed
• New form and strength
  New tablet formulation of KALETRA (lopinavir/ritonavir) has potential for confusion.
• “Time outs” work
  Look alike and sound alike similarities between BREVIBLOC (esmolol) and BREVITAL (methohexital) create near miss situation.
• Lithium in mg or mEq
  Confusing between units results in two errors in lithium dosing.
• Nimodipine alert
  Thanks to your reports, changes will be made to NIMOTOP (nimodipine) labeling.
• Benzocaine Public Health Advisory
  FDA published a new Public Health Advisory (2/10/06) concerning the risk of methemoglobinemia associated with the use of topical benzocaine sprays. Two days earlier, the VA health system removed benzocaine sprays from their practice guidelines.

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