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The following are excerpts from the newsletter

July 12, 2000

  • Misuse of liquid phosphate laxatives used for bowel preps
  • ISMP Quarterly Action Agenda: April - June, 2000
  • Safety Briefs:
    • Wyeth-Ayerst Laboratories recently marketed MYLOTARG (gemtuzumab ozogamicin for injection) is extremely light sensitive. Wyeth recommends protection from direct and indirect sunlight and unshielded fluorescent light during preparation and infusion.
    • Keep in mind that I.V. SPORANOX (itraconazole) should not be used in patients with a creatinine clearance less than 30 mL/minute. Hydroxypropyl- beta-cyclodextrin, a vehicle used in manufacturing the intravenous product, has reduced clearance in renal failure patients.
  • Announcements
    • Because the ISMP Medication Safety Self AssessmentTM took longer than expected to reach organizations after mailing it, the deadline for submitting data to ISMP has been extended to August 31, 2000. Please notify us at 215 947 7797 if the director of pharmacy in your facility did not receive a copy.
    • For ISMP, nothing is more important than being able to get information from the USP-ISMP Medication Errors Reporting Program (MERP) and other sources, then translating the misadventures into useful learning experiences for the healthcare community at large. At this time, ISMP does not receive information from USP's new MedMARx program. If your hospital subscribes to MedMARx, we encourage you to continue to report errors and hazardous situations to the USP-ISMP MERP so that ISMP can share insights and blinded information with the entire medical community. Alternatively, call errors into 1-800-23 ERROR or 1-800-FAILSAF(E), or link to the report form on the ISMP and USP web sites. Reporters can elect to remain anonymous, however, those who choose to report their name can rest assured that USP and ISMP hold reporter identity and location in strict confidence.
    • We'd like to hear from you if you are aware of an individual, hospital, health system, or company that has done something extraordinary in the area of medication safety this year. ISMP recognizes outstanding contributions to medication safety annually at our Cheers Award banquet during the ASHP Midyear Clinical Meeting, held this year, December 3-7, in Las Vegas. If you would like to enter a nomination for this award, please let us know. Our board of trustees selects awardees based on the information submitted. Cheers awardees are provided with a beautiful crystal figurine as well as reimbursement for travel expenses to attend the dinner.

July 26, 2000

  • JC has it right - pharmacists should review all non-urgent drug orders prior to administration
  • OPPS or OOPS? New outpatient prospective payment billing system could compromise safety
  • Safety Briefs:
    • Handwriting continues to cause confusion between AVANDIA and COUMADIN.

    • Picture of order for AVANDIA

    • Handwriting confusion between TEGRETOL and TEQUIN.

    • Picture of order for Tequin

    • The ISMP Quarterly Action Agenda is now approved for 1 hour (0.1 CEU) of continuing pharmaceutical education credit by PSHP. Learning objectives and instructions to apply for continuing education are available on the ISMP home page ( by clicking on the most recent Quarterly Action Agenda.
    • Another mix-up reported between liposomal doxorubicin (DOXIL) and conventional doxorubicin (ADRIAMYCIN, RUBEX, and others).
    • ISMP has been working with counterparts in Canada to establish momentum for a national medication error prevention effort there. As a result, a nonprofit agency, known as ISMP-Canada, has been created.
    • Recently graduated health professionals may have acquired some unsafe practices, sometimes learned from teachers. For example, a nursing student documented a sliding scale coverage dose of regular insulin as "12 units" on the medication administration record only to have it "corrected" by an instructor to "12 U."

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