ISMP
ISMP
Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP
ISMP
ISMP Facebook

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.

subscribe now

Resources
Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Subscribe
Newsletter Editions
Acute Care
Community/Ambulatory
Nursing
Long Term Care
Consumer
ISMP 17th Annual Cheers Awards
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2014 Institute for Safe Medication Practices. All rights reserved

 
ISMP
ISMP