The following are excerpts from the newsletter
January 13, 1999
- Massachusetts Board action
will hurt patients
- New initiative to prevent look-alike/sound-alike errors
- ISMP and LaSalle University receive research grant
- Safety Briefs
- FDA has requested that TROVAN manufacturer,
Pfizer, modify the package insert to include a list
of diluents that are not compatible including 0.9% sodium
- Look-alike warning! We've had several reports about
American Regent's phenylephrine HCl 1% (10 mg/mL) in
1 mL single dose vials being confused with Elkins-Sinn's
prochlorperazine edisylate 10 mg/2 mL (5 mg/mL) in 2
mL single dose vials.
- We've received a number of calls about the name chosen
by Searle for their new COX2 inhibitor, CELEBREX
(celecoxib), co-marketed by Pfizer, which was approved
on January 5, 1999. Practitioners have expressed concern
about possible confusion between Celebrex and CEREBYX
- Unfortunately, we recently heard about an error where
the newly formulated VERSED SYRUP (15 mg) and TYLENOL
(acetaminophen) LIQUID (650 mg) were drawn up in a parenteral
syringe and administered IV to an 11-year-old child
being prepared for surgery.
- A container of 5% acetic acid, used for cleansing
a patient's trach tube, was left next to nebulization
equipment in a patient's room. A respiratory therapist
diluted albuterol with the acetic acid instead of saline,
then administered a nebulization treatment.
- IMPORTANT! Please don't forget to complete the computer-users
- ISMP recommendation: Return
CEREBYX until package labeling revised
- ISMP announces medication safety fellowship.
- Ten simple ways to put information from ISMP Medication Safety Alert! to use
- ISMP Action Agenda: Items from ISMP Medication Safety Alert!, October-December, 1998
- Safety Briefs
- A pharmacist misread a handwritten prescription for
"Insulin N 70/30 10U qAM &8U qPM" as 10 units every
morning and 28 units every evening when the prescriber
placed the ampersand very close to the intended 8 unit
- Glaxo Wellcome has notified health professionals of
rare case reports of asthmatic patients on inhaled FLOVENT
(fluticasone propionate) presenting with systemic eosinophilic
conditions, some with clinical features of vasculitis
consistent with Churg-Strauss syndrome
- For the first time in memory, a pharmaceutical company
has agreed to redesign the label for an established
drug product label to prevent dosing errors due to confusion
with a competitor's product. Bristol-Myers Squibb's
Apothecon Division has received FDA approval for an
amphotericin B labeling supplement, which adds a STOP
sign with the statement: "STOP: Verify product name
and dosage if dose exceeds 1.5 mg/kg."
- IMPORTANT! Please don't forget to complete the computer
field test and survey that was re-sent January 13th.
- FDA is alerting consumers not to consume products
that contain gamma butyrolactone (GBL). FDA has also
asked the companies that manufacture these products
to voluntarily recall them.
- ISMP gives thumbs down to a proposal by New Jersey's
State Board of Pharmacy to amend regulations to require
that pharmacy directors notify the board within 7 days
of becoming aware of a "significant medication error."
The board believes that this action will promote patient