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The following are excerpts from the newsletter

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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