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The following are excerpts from the newslette

January 10, 2001

  • In the long run, penmanship classes for doctors won't do much for patient safety
  • Think you've "heard" it all? How about fraudulent telephone orders?
  • Hazard Warning
    Bedford Laboratories products with look-alike similarities.
  • Safety Briefs
    • A physician accidentally gave a nurse telephone orders for a heparin infusion via protocol in addition to a low molecular weight heparin (LMWH) product twice a day. Both medications were available in a night cabinet for use when the pharmacy was closed. The error was recognized when the pharmacist reviewed the nighttime orders upon arrival at the hospital the following day. Unfortunately, the patient died from intracranial bleeding.
    • In our December 13, 2000, issue, we wrote "the dosage of parenteral calcium should be standardized at each practice site and be based on the amount of elemental calcium rather than the mg strength of the salt." However, unlike other parenteral electrolyte salts such as potassium and magnesium, the primary label panel on vials of calcium gluconate and calcium chloride, as well as commonly used references, continue to express the dose in terms of the amount of the salt in grams. Regardless of the method used, the most important error reduction strategy is to select just one standard way to dose calcium at each institution.
    • Three residents of a Midwestern nursing home died after a nitrogen tank was accidentally connected to the facility's oxygen system. The cryogenic tank involved in this incident was noted to have an oxygen label that was partially covered with a smaller nitrogen label.
    • Readers in Spain can use the Internet to obtain safe medication practice information. Our Spanish affiliate, headed by Dra. Maria Jose Otero of the University of Salamanca in Salamanca, Spain, posts safety alerts and accompanying photographs at Also, Canadian pharmacists should visit ISMP Canada is headed by Canadian pharmacist David U.
    • Looking for ISMP-recommended error prevention strategies to incorporate into your quality improvement efforts? All issues of the ISMP Medication Safety Alert! from the past five years (January 1996 to December 2000) are now available on compact disc in Adobe PDF format with the Adobe Acrobat Reader included. Articles are fully searchable and may be copied for internal use. The price is $75. Visit our online store to place an order. Purchase orders and major credit cards are accepted.

January 24, 2001

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