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The following are excerpts from the newsletter

January 14, 1998

  • 1997 Cheers & Jeers
  • Versed label changes not endorsed by ISMP
  • Safety Briefs
    • Hospital contacts parents of 30 infants who may have received promethazine instead of phtonadione due to packaging similarities. All 30 infants were given additional doses of phytonadione (Vitamin K).
    • Roche issues "Dear Doctor" letter warning about suppression of sinoatrial activity and sever bradycardia associated with Posicor® (mibefradil). Letter contains information on contraindications as well as the warning above.
    • Please participate in the potassium chloride survey.
    • Educate staff about proper dilutions of albumin. Large volumes which have been diluted with sterile water can cause hemolysis.
    • Dosing information on amphotericin B deoxycholate in Facts & Comparisons on page 357d is incorrect and will be corrected in the March updates. Dose is for the entire course of therapy not the daily doses.
    • Looks like.... A hospital patient recently used Hemocult® SENSA (occult blood developer) as an eye drop because the container looked like an eye dropper.
    • FDA is considering recommendations to help minimize medication errors by having the pharmaceutical industry do pre-approval testing of product labeling, packaging and proprietary names.
    • At the request of some subscribers, ISMP is offering sets of 1996 and 1997 newsletters for $35 each. Also if you receive the newsletter by fax and your area code has changed, let us or your buying group know so that you will not miss any issues.

January 28, 1998

  • Proposed HCFA rule may cause increase in medication errors
  • HAZARD ALERT! Time for a look at Brevibloc storage outside the pharmacy
  • HAZARD ALERT! Confusion over liposomal products can lead to serious patient harm
  • Improperly stored non-drug substances used during surgical procedures may be at root of some medication errors.
  • Safety Briefs
    • Don't depend on automated dispensing cabinets alone to prevent medication errors.
    • Use caution when handling Bausch and Lomb ophthalmic products. Many of its recently repackaged ophthalmic solutions and ointments are in the same size boxes with highly stylized white, blue/tan coloring along with a picture of a human eye. They can easily be mixed-up with one another. In fact, due to the look-alike packaging and similar drug names, one hospital has reported frequent mix-ups.

    • Thanks to everyone who returned the potassium chloride concentrate injection fax poll
    • Pharmacists can earn ACPE-accredited continuing education credits by reading the ISMP Medication Safety Alert
    • Institute for Healthcare Improvement (IHI) will launch the second Breakthrough Series Collaborative on Reducing Adverse Drug Events and Medical Errors in February, 1998. For information, call Rebecca Steinfield at 617 754 4825.
    • ISMP will conduct a full day seminar for members of the pharmaceutical industry to discuss industry's role in helping health professionals eliminate medication errors. The meeting will take place in Princeton, NJ on April 3rd. Call ISMP at 215 947 7797 for more information.
    • A board certified nephrologist recently ordered dialysate containing an amount of gentamicin appropriate for a single daily IV dose (320mg) rather than an amount that would equilibrate with with therapeutic blood levels (6-8 mg/L). For some reason the physician directed the patient to a community pharmacy rather than a hospital pharmacy to fill the prescription. The community pharmacist dispensed the prescription as written even though he was not familiar with this method of administering the drug. The patient subsequently experienced acute hearing loss, which has not improved. Pharmacists have a duty to have a working knowledge of any medication that they are asked to dispense.
    • Two of the three Colorado nurses charged with criminally negligent homicide in a baby's death accepted a deferred guilty plea with the understanding that their criminal records would be withdrawn if they experience no incidents during the next two years. The nurses also agreed to perform community service. The third nurse did not accept the plea, and she goes on trial this week. An ISMP pharmacist is assisting in the nurse's defense by serving as an expert witness on system failures

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